#101 13711-72nd Ave ,
Surrey, BC,
Canada V3W2P2
PH: 1-800-998-4016
Toll Free Fax: 1-866-868-2303
www.mapleleafmeds.com

WHAT'S NEXT?
1.	Each prescription is reviewed by a licensed and professionally registered physician.
2.	Prescriptions are filled by a licensed pharmacist and sent to your home
PET MEDS CHECKLIST
I have completed patient information form I have signed the consent form I have a witness signature on the consent form My pets prescription(s) are less than 2 months old I am aware that it may take 3-4 weeks to receive my order*
	CHARGES - 3 month supply with three-month refill - no restriction on number of prescriptions.
	* If your order is canceled after the doctor review and before it is shipped, we will assess a $20 administrative fee. Once an order has been shipped, there is no cancellation. All sales are final.
PLEASE NOTE Maple Leaf Meds facilitates the review of your pet's prescriptions and your medical health by a licensed Canadian veterinarian and forwards all prescriptions to an affiliated, certified licensed pharmacy to be filled. Prescriptions are currently dispensed by the following certified pharmacy: Coastal Canada Pharmacy #1006-7495 132nd Street Surrey BC V3W 1J8 Pharmacy Manager: Grace Kim (LIC: #08001)
	Please feel free to call us Toll Free 1-800-998-4016 if you have any questions.

#101 13711-72nd Ave , Surrey, BC, Canada V3W2P2 PH: 1-800-998-4016 Toll Free Fax: 1-866-868-2303 www.mapleleafmeds.com

PET AND OWNER INFORMATION

Pet Name: __________________________ Species (and breed):__________________________

Age of Pet:_______________________Weight:_______________________Gender:____M____F

Allergies (if no, write "NONE"):____________________________________________________

Known Medical Conditions: ______________________________________________________

Spayed or Neutered:____________________________________________________________

Vaccination History:_____________________________________________________________

List other medications pet is currently taking:_________________________________________

Owner:________________________________________________ DOB:____________________

Phone Number: (_____)________________Secondary Phone Number:(_____)________________

Home Address:______________________________________________Apt:__________________

City:________________________________ State:__________________ ZIP Code: ___________

Email:________________________________

Last Name:_____________________________ First Name: ___________________________

Address: ____________________________________________________________________

City: ______________________ State: _____________________ZIP Code: ______________

Telephone: (_________________) Fax: (__________________ )* REQUIRED

Please Note: We do not usually ship medications in child-proof containers. If you require child-proof containers, please indicate by checking here _____

How did you hear about us?________________________________________________________

Is this your first time ordering from Maple Leaf Meds?______Yes _______No

I understand that I am ordering from an international pharmacy and that once the pharmacy ships my medications, all sales are final. We are unable to take returns.

CREDIT CARD INFORMATION AND AUTHORIZATION

Cardholder Name:___________________________________

Type of Card________________________________________

Printed Name of Patient_______________________________

Signature___________________________________________

Visa or Mastercard Only

I, __________________ authorize Maple Leaf Meds to apply all applicable charges to my credit card.

#101 13711-72nd Ave , Surrey, BC, Canada V3W2P2 PH: 1-800-998-4016 Toll Free Fax: 1-866-868-2303 www.mapleleafmeds.com

Consent and Waiver of Liability Form

I ____________________ of the city of ________________ in the state of ___________ have read, understood and agree to the following:

1. I, __________________ am not seeking medical advice or treatment of any kind whatsoever in coming to Maple Leaf Meds and its physicians, employees, officers, agents and all others acting through or for it.
2. Neither Maple Leaf Meds, nor any of its physicians, veterinarians, employees, officers agents and all others acting through or for it, or anyone that is acting on its behalf, is providing medical advice, professional advice, treatment advice or treatment of any kind whatsoever to me or my pet.
3. I am coming to Maple Leaf Meds for the SOLE PURPOSE OF OBTAINING A PET PRESCRIPTION AT A LOWER PRICE THAN IN THE UNITED STATES OF AMERICA. I understand that no one on behalf of Maple Leaf Meds will take any steps whatsoever to determine whether the prescription is appropriate.

I _________________ hereby acknowledge that this prescription was originally prescribed by my pet's American veterinarian whose name is __________________________ and that I will continue to have my pet's medical condition and medications obtained in Canada monitored by my American veterinarian upon my return to the United States of America.

I, ________________ have given the authority to Maple Leaf Meds to act as my agent and/or representative to facilitate the purchase of prescription medicine from a licensed Canadian pharmacist.

In consideration of approving this prescription and in consideration of Maple Leaf Meds making this prescription, I agree not to sue Maple Leaf Meds, its physicians, veterinarians, employees, officers, agents and all others acting through or for it, and release Maple Leaf Meds, its physicians, veterinarians, employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription.

I hereby agree that the relationship between and the resolution of any and all disputes arising between me and Maple Leaf Meds, its physicians, employees, officers, agents and all others acting through or for it, shall be governed by and construed in accordance with the laws of the State of Washington, U.S.A.
I hereby acknowledge that the Courts of the State of Washington shall have jurisdiction to entertain any complaints, demands, claims or cause of action, whether based on alleged breach of contract or alleged negligence arising out of the signing of this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts of the State of Washington.

All of which is agreed.

Fax, mail or scan the pet information forms along with the prescriptions to:

#101 13711-72nd Ave ,
Surrey, BC,
Canada V3W2P2
PH: 1-800-998-4016
Toll Free Fax: 1-866-868-2303
www.mapleleafmeds.com

FORM UPDATED: 02/12/2010