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


Step 1 Fill out the customer information section with your SHIP TO address.
Step 2 Please fax or mail your completed forms. Send a copy of ORIGINAL PRESCRIPTION(S) if necessary. Please contact Maple Leaf Meds at the toll-free number above if your are uncertain if you need new prescriptions.

REFILL / EXISTING CUSTOMER FORMS

Customer Information:

Name: _________________________ Phone Number: ________________Date:_______________ DOB: ___________

Home Address:____________________________________________________Apt:___________

City: _________________________ State: ___________________ZIP Code: ______________

Requested Medications (call us 1-800-998-4016 or visit us online for price quotes) Dosage
   
   
   
   
   
   
**Please list additional medications on a separate page  

Unless specifically requested, generic substitution is automatic. We advise our customers to always compare our prices with their local pharmacy.

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

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: ______________________________________ Circle One: Visa / MasterCard
Credit Card Number: _____________________ Expiry Date ___________________
I, __________________ authorize Maple Leaf Meds to apply all applicable charges to my credit card.
Cardholder Signature: _________________________
Printed Name of Patient:_____________________________

Medical Information Form

Would you like a physician to call you? ____ Yes ____ No
Would you like a pharmacist to call you? ____ Yes ____ No

Known Drug Allergies:______________________________________________________________

a) Blood Disorder _____Yes _____No h) Upper respiratory disorders _____Yes _____No
b) Cancer _____Yes _____No i) Smoker _____Yes _____No
c) Renal or Kidney Disease _____Yes _____No j) Emotional Disorders _____Yes _____No
d) Neurological Disorders _____Yes _____No k) Glaucoma _____Yes _____No
e) Hyperlipidemia _____Yes _____No l) Stomach, Liver, Intestine Disorder _____Yes _____No
f) Arthritis _____Yes _____No m) Thyroid, Diabetes or otherendocrine disorder, including insulin resistance _____Yes _____No
g) Heart Disease including blood pressure, heart disease, angina, heart failure, heart attack, surgery _____Yes _____No      

Please list any surgeries and/or misc. applicable health information
_________________________________________________________________________________
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REVISED 02/12/2010