Thank you for your interest in our online pharmacy prescription service. Customers can easily obtain their medications from Canada. Our prescription service allows customers to conveniently access
the same medications that are available to them locally.

If you need any information regarding the price of your prescription please contact us toll-free at
1-866-456-2456 or visit our website at www.UniversalDrugstore.com.

Ordering Your Prescription:
Step 1: Please complete the following medication order form. Any information you provide will be kept strictly confidential. You will only have to fill out this order form the first time you order form us.

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, American Express, Discover, checks, International Money Orders, and Automatic Banking Withdrawal made out to ‘UDS Health’. There is a short waiting period for banking authorization on personal checks.

Shipping:
The shipping fee is a flat rate of $7.00 per package. (Not per drug, but per shipment).

Please Be Advised:
Government regulations 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.

Many insurance companies will accept receipts issued from a Canadian pharmacy, however, patients with drug insurance plans should check with 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

Date of Application      ___________________

Full Name _______________________ Age ______________________
Address _______________________ Height ______________________
City _______________________ Weight ______________________
State/Province _______________________ Sex ______________________
Zip/Postal Code ________________________ Date of Birth (dd/mm/yyyy) ______________________
Country ________________________ Occupation (Optional) ______________________
Phone (Home) ________________________ Referral Source (Optional) ______________________
Phone (Work) ________________________    
Email ________________________  

Primary Physician Name _____________________________________________________
Address _____________________________________________________
Phone _____________________________________________________
Fax _____________________________________________________

 Please indicate any known drug allergies you may have:

Credit Card Information

Credit Card Type Visa MasterCard Discover American Express
Credit Card Number
CVV Number
Expiry Date /

Name on card

 __________________________________________________________
Signature __________________________________________________________

Address

 __________________________________________________________

City

 __________________________________________________________

State

 _______________________________ Zip/Postal Code __________

_________________________________________   _________________________________________

Patient's Name (Print)

  

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.

Allowing generics may save you up to an additional 30%

Brand
Name
Only
Generics
permitted
QTY
 Medication/Directions
 Strength

Illness/Diagnosis Price USD
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
     
for
    
Add $7.00 Shipping & Handling(Trackable Insured Shipping via Express Post)
 $7.00     
(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.

Other Medications You Are Currently Taking

This is for our records only and will be kept strictly confidential. Listing other medications that you are currently taking will help us create a more complete medical history for you.

Medication/Directions
Illness/Diagnosis
 
for
  
 
for
  
 
for
  
 
for
  

Patient Medical Questionnaire

_________________________________________   _________________________________________

Patient's Name (Print)

  

Patient's Signature

1) High Cholesterol Y ___ N ___ 11) Glaucoma or other eye disorder Y ___ N ____
2) High Blood Pressure Y ___ N ___ 12) Kidney disease Y ___ N ____
3) Diabetes Y ___ N ___ 13) Liver disease Y ___ N ____
4) Heart Disease or Stroke Y ___ N ___ 14) Muscle or joint disorders such as arthritis, gout, fibromyalgia, carpal tunnel Y ___ N ____
5) Edema or excessive fluid retention Y ___ N ___ 15) Emotional disorders such as depression, psychosis, etc. Y ___ N ____
6) Gastrointestinal diseases such as ulcers,
gastroesophageal reflux, ulcerative colitis or Crohn’s disease		 Y ___ N ___ 16) Immune disorders such as HIV, AIDS, Lupus etc. Y ___ N ____
7) Thyroid disorder Y ___ N ___ 17) Allergies to dust, pollen, etc
Y
 ___
N
 ____
8) Cancer Y ___ N ___ 18) Skin disorders such as acne, psoriasis, etc Y ___ N ___
9) Lung or upper respiratory diseases Y ___ N ___ 19) Neurological disorders such as Parkinson’s, seizures, Alzheimer’s, stroke, migraines, etc. Y ___ N ___
10) Smoker Y ___ N ___ 20) Prostate disorder Y ___ N ___

Important: If you answered YES to any of the above questions or you have any other illness not noted above please elaborate in the box below:

 

 

 

Authorization and Release Form
Universal Drug Store Ltd.

I, the Undersigned, hereby represent and confirm to U.D.S. Health Inc. and Universal Drug Services, which carry on business as universaldrugstore.com ("UDS") and to each of their affiliates, associates, Fulfillment Pharmacies (defined below), related companies, subsidiaries, parent company, and each of their respective directors, officers, shareholders, employees, contractors, subcontractors, successors and assigns (collectively referred to as “UDS“) that:

 

  1. I am delivering this Agreement to UDS for the purpose of placing an order for certain medications ("Ordered Products") on the terms and conditions set out herein.
    2.
  2. I am of the age of majority in the jurisdiction in which I ordinarily reside (the "Place of Residence") and am not restricted from making my own medical decisions under the laws of my Place of Residence.
    3.
  3. The Ordered Products were prescribed to me by a duly qualified medical practitioner ("My Doctor") in my Place of Residence, or where I sought treatment and no laws have been violated in obtaining the prescription ("My Prescription") for the Ordered Products.
    4.
  4. The Ordered Products will not be used in any way whatsoever, except as prescribed by My Doctor, and as such will be used only by me.
    5.
  5. My Prescription has not been altered in any way, nor has it been filled prior to submission to UDS. I agree to immediately destroy all copies of My Prescription once it has been filled.
    6.
  6. It is my responsibility to have regular physical examinations by My Doctor that is responsible for my care, including all suggested testing, to ensure that I have no medical conditions or problems which could cause adverse effects to me by taking the Ordered Products. I will immediately contact My Doctor in the event I suffer any unexpected side effects from any of the Ordered Products.
    7.
  7. UDS has and will continue to rely on the information and documentation that I am providing to them, and I represent and confirm that I have fully and truthfully disclosed all pertinent information and documentation to UDS. I agree to notify UDS of any changes to my physical or medical condition.
    8.
  8. I hereby authorize and appoint UDS as my agents and attorneys for the limited purpose of taking all steps and signing all documents on my behalf which are necessary to permit the delivery of the Ordered Products to me, to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization shall include, but not be limited to: collecting personal health information about me; collecting similar information from My Doctor or pharmacist, and disclosing that personal health information to UDS employees, agents, contractors, subcontractors, affiliates, service providers, and fulfillment pharmacies, including without limitation any physicians, any Fulfillment Pharmacies, and any pharmacist being engaged on my behalf (collectively "My Agents"), as required, for the limited purpose of obtaining my Ordered Products. Neither UDS nor My Agents provide their agency or attorney services as a substitute for the advice of My Doctor.
    9.
  9. I hereby specifically acknowledge and consent that UDS will be transmitting my personal health information by electronic (for example fax, or secure internet) or verbal means to My Agents. UDS, as a custodian of my personal health information, will take all appropriate precautions to protect my personal health information from disclosure or improper use.
    10.
  10. Title to the Ordered Products passes from UDS to me a the time the Ordered Products leave Universal Drug Services or any of U.D.S. Health Inc.'s affiliated Fulfillment Pharmacies.
    11.
  11. I specifically acknowledge and agree that any and all agreements reached or contracts formed throughout the course of my purchase of my Ordered Products, and also in respect to any dispute that may arise between me and UDS or My Agents, shall:

    A. in respect of any Ordered Products that are dispensed by UDS, in the Province of Manitoba, Canada, shall accordingly be governed by the laws of the Province of Manitoba, Canada.

    B. in respect of any Ordered products that are dispensed by any Fulfillment Pharmacies in their respective jurisdiction, shall accordingly be governed by the laws of that respective jurisdiction.
    12.
  12. The providers reserve the right to not accept any order cancellations after 48 hrs. of receiving your order. Cancelled orders may be subject to a cancellation fee.
    13.
  13. As per The Pharmaceutical Act of Manitoba Regulation 23(1) "A pharmacist shall not accept for return to inventory any drug that has been previously dispensed". The Ordered Products may not be returned for a refund or an exchange.
    14.
  14. If the Undersigned is placing the order on behalf of someone else, the Undersigned represents that they have all necessary consent, permission and authorization to do so on behalf of that person and their heirs, agents and successors and the person they represent agrees to all of the above terms and conditions, understands all of the above conditions and has had an adequate opportunity to consult any advisors necessary, whether medical, legal or otherwise.
    15.
  15. By agreeing to this document I confirm that I have read and understood these terms and conditions and that these terms and conditions will apply to and govern any orders by me of medications from UDS, unless I specifically indicate otherwise at the time of ordering such medications. Without limiting the forgoing, each authorization and consent provided by me in this agreement will continue until I cancel such authorization or consent (which I can do at any time).
    16.

Signature: X ________________________________ Print Name:________________________

Date: ______________________________________


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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