Canadian Medication
Order Form
Referral Code: CH055		 Redwood Drugs Pharmacy
1076 A Main Street
Winnipeg, Manitoba, R2W 5J3
phone: 1-866-211-3768
fax: 1-866-287-1595
Original Prescriptions must accompany this form - faxed or mailed in.
 You can print this form on your printer by hitting the " Ctrl " key and " P " key at the same time. That will bring up your printer window. After  you have filled out the information just fax it in to the above fax number or mail to the above address.

Name: _______________________________

 Date of Birth: ________________________
Address: _____________________________ City:____________St:_____ ZIP: ________
Home Phone: (         ) ____________________ Work Phone: (           ) __________________
Fax: (         ) ___________________________ Email: _____________________________
Doctor's Name: ________________________ Doctor's Phone Number: (           ) ____________
Patient Requested Medication
Requested Medication Dosage (mg.) Quantity Price
       
       
       
       
       
       
       
    Add Shipping

$14.95
    Total Enclosed  
 I hereby waive my right to pharmacy counseling, as I have been previously counseled regarding the above medications. (Optional)
 Please do not contact me regarding this order, but rather ship the medication as described above. (Optional)

Payment Method

______ Mastercard   ______ VISA   ______ Money Order   ______ Certified Check
Name: _______________________________ Credit Card # ______  _______  _______  _______
Signature: ____________________________ Date:_________________ Exp: ____________

How to Order:
1. Mail or fax this form along with the release form, patient allergy form AND prescriptions (with as many refills as you might need later).
2. We verify the prescription with our team of physicians.
3. We contact you for payment if necessary (please ensure that your name and phone number are on the prescription).
4. The prescription will be sent to your home. Shipping cost is $14.95 per order. New prescriptions generally take up to 3 weeks for delivery. Refills generally take 2 weeks for delivery.
Our toll-free fax number is 1-866-287-1595. If you have any questions, please call us at 1-866-211-3768.