Form B


Thank you for choosing universaldrugstore.com. If you have ordered prescriptions from us before, please use this form to order your new prescriptions. You do not need to fill our other patient questonnaire or sign another release form to fill a new prescription. If you need any information regarding the price of your prescription please contact us toll-free at 1-866-456-2456 or by email at pricequotes@universaldrugstore.com.

Ordering Your Prescription:
Step 1: Fill out the short prescription order form. Please note any changes in your address or medical condition.

Step 2: Simply mail the information back to us, or to save mailing time, fax it toll-free to 1-866-783-4223.

Mail to:
Universal Drug Services
PO BOX 2581
STN MAIN 266 GRAHAM
Winnipeg, MB
R3C 4B3

Payment:
We accept VISA, MasterCard, checks and money orders made out to
universaldrugstore.com. There is a short waiting period for banking authorization on personal checks.

NOTE: We are offering $5 off your first order using Automatic Banking Withdrawal as your payment option.

Shipping:
The shipping fee is a flat rate of $10.00 per package in the US. (Not per drug, but per shipment). Shipping costs to other countries may vary.

Please Be Advised:
The U.S. FDA limits the quantity of medication that you can order to a maximum of a 3-month supply. If your prescription allows refills, you can simply call us to order your refill.

We are not allowed to ship controlled substances such as amphetamines, benzodiazepines (e.g. Valium), or narcotics such as codeine and morphine.

Most American insurance companies will accept receipts issued from a Canadian pharmacy, however, patients with drug insurance plans should contact their insurance company first before ordering.

Our service is open to anyone. Please feel free to give our toll-free number or website address to friends and family, or to make copies of our order form for other people.

Contact Us:
Toll-Free Phone:   1-866-456-2456
Toll-Free Fax:      1-866-783-4223
Email:     info@universaldrugstore.com

 

Patient Information

Full Name _______________________ Has anything changed in your health or the medication you take?
Address _______________________ ____________________________
City _______________________ ____________________________
State/Province _______________________ ____________________________
Zip/Postal ________________________ ____________________________
Country ________________________ ____________________________
Phone (Home) ________________________ ____________________________
Phone (Work) ________________________   ____________________________
Email ________________________ ____________________________

_________________________________________

Patient's Signature

Medication Being Ordered

Important (Please read carefully): In the spaces provided below please write the medications that you would like us to fill for you at this time. Any medications not written here, but which you have sent a prescription for, will not be filled at this time. These medications will be filed on our computer and can be filled at a later date.

QTY = quantity (i.e. number of tablets). Please be sure to specify brand name or generic preference.

Brand
Name
Only
Generics
permitted
QTY
 Medication/Directions
 Strength

Illness/Diagnosis Price USD
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
Add $10.00 Shipping & Handling(Trackable Insured Shipping via Express Post)
 $10.00     
(Payment in U.S. Funds) Total Enclosed
  

Please note that we will fill your prescriptions where applicable in the manufacturer’s sealed containers. For example, if your prescription calls for 90 tablets, but the manufacturer supplies bottles of 100, we will fill for 100 tablets.

Your Prescription

 

Attach Prescription Here

(Please ensure that we can see the entire prescription)
Please use additional pieces of paper if you cannot fit all
of your prescriptions in the designated area.

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