West Vancouver, BC
Canada V7T 1B9
PH: 800-998-4016
Toll Free Fax: 877-887-5321
www.mapleleafmeds.com
|
207
- 1425 Marine Drive West Vancouver, BC Canada V7T 1B9 PH: 800-998-4016 Toll Free Fax: 877-887-5321 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:____________________________ KEYCODE:_________ Veterinarian Information: 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 _____ 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 _____________________
Expiry Date ___________________ Credit Card Number: ____________________________ I, __________________
authorize Maple Leaf Meds to apply all applicable charges to my credit
card. Signature: _________________________ Consent and Waiver of Liability Form I ____________________
of the city of ________________ in the state of ___________ have read,
understood and agree to the following: 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 pet's 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. All of which is agreed. Printed Name: __________________________________ Fax, mail or scan the pet information forms along with the prescriptions to:
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
