Canadian Pharmacies Online - Canada Pharmacies

Medicare Part D Prescription Drug Alternative

Canadian Pharmacies Online - Canada Pharmacies: Fill out the form below and fax your prescription to 661-420-6627. Allow 14 days for delivery from the time we receive all paperwork.

If you would like a form to fax or mail click here.

Any questions e-mail: medsforless@gmail.com or call (800) 615-0868.

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Please tell us how you found us. *

First Name *		Last Name *		M.I.

Home Address *		City *		State *		Zip *

Home Phone *		Work Phone

Allow us to send an occassional e-mail containing useful information and receive savings up to 65% on all U.S. drug purchases - free!		E-mail address

Date of Birth *

Sex *

Height *

Weight *

Have you been examined by a qualified medical doctor within the last 12 months? *

Yes

Any history of kidney disease? *

Yes

Any history of liver disease? *

Yes

Smoking? *

Yes

Please tell us about any illness or medical condition you may have.

Please list all allergies:

Please list all current medications (including over the counter and herbal)

* By submitting an order, I hereby confirm that all information is true and correct to the best of my knowledge and, I consent to my doctor being contacted if additional medical information is required. Click box below and continue to next section.

* Required to submit this form

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