Mail / Fax Order Form

Fax to: 1-866-721-1308

Or mail to:
Suite #223 7360-137 Street
Surrey, BC, Canada
V3W 1A3

Cover Sheet

Total Number of Pages (including this sheet):  

Your Name (as written on prescription):  

1. Complete and sign the attached form

2. Fax toll-free 1-866-721-1308

** Please note: All prescriptions will be authorized for a 1-year period if indicated by the physician and will be honored from the date on the prescription form. All prescription drug prices include pharmacy dispensing fee.

Please Attach Prescription to the Box Below Before Faxing:

Attach Prescription Here


Order Details

Medication 1 Qty
Medication 2 Qty
Medication 3 Qty
Medication 4 Qty
Medication 5 Qty
Medication 6 Qty
Medication 7 Qty
Medication 8 Qty
Medication 9 Qty

Billing Address

First Name:
Last Name:  
City / Town:  
State / Province:  
Zip / Postal Code:  
Alternate Phone:  


Shipping Address

First Name:  
Last Name:  
City / Town:  
State / Province:  
Zip / Postal Code:  


Shipping Preference

Normal Shipping - $9.95 per order

Payment Method

For added security, a customer service specialist will call to collect credit card information.     We proudly accept:

Medical History

A Health Specialist will contact you to review your medical history on the phone.


Terms of Agreement

No prescription(s) will be filled until a signed and dated copy of this Terms of Agreement and a completed Patient Profile have been received by These documents can be sent by fax to:



I, the undersigned, acknowledge, represent and confirm to and to York Pharmacy (hereinafter collectively referred to as "") that:

The prescription(s) that I submit to for the medications (referred to in this Agreement as "pharmaceuticals" or "medications") described in the prescription were prescribed by a physician ("My Doctor") licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside or where I sought treatment and who I personally consulted.

The prescription(s) were lawfully obtained by me from My Doctor.

I will continue to have my medical condition and my use of the pharmaceuticals obtained through monitored by My Doctor on a regular basis as My Doctor may advise me.

I am engaging for the sole purpose of obtaining prescription medications at a lower price than in the country in which I reside.

I am not seeking medical advice or medical treatment of any kind or nature whatsoever from nor am I relying upon any medical information from or from any of its employees, officers, agents or any and all others acting through or for

I understand that neither nor any of its employees, officers agents and all others acting through or for it, nor anyone that is acting on its behalf, is providing medical advice, treatment advice or treatment of any kind whatsoever to me.

I will use any pharmaceuticals obtained for me by strictly according to the instructions provided by My Doctor.

The pharmaceuticals will only be used as directed and only by me.

I can make my own medical decisions according to the law of the place where I reside.

The prescription(s) for the pharmaceuticals has not been altered in any way nor has it been filled prior to submission to

I will immediately contact My Doctor in the event that I suffer any side effects from any pharmaceuticals.

It is my responsibility to have regular physical examinations by My Doctor including all testing to ensure that I have no medical problems which would constitute a contradiction to me taking the pharmaceuticals.'s employees and agents have relied on the information and documentation that I have provided or will provide (including the Patient Profile) and I represent and confirm that I have fully disclosed all pertinent and relevant information and documentation to I agree to promptly notify of any changes to my physical or medical condition by providing an updated Patient Profile.

I understand that:

B. AUTHORIZATION AND CONSENT half, as required, for the limited purpose of obtaining the Canadian prescription. The authorizations and consents that I am providing to commence on the date I have signed this agreement and shall continue until I revoke them. I understand that I can revoke the consents and authorizations I have granted to at any time.

I hereby specifically acknowledge that I am aware that will be transmitting my personal health information by electronic means (for example fax, secure internet) to its affiliates and service providers including the Canadian physician retained by on my behalf to obtain the Canadian prescription(s). I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that, as a custodian of my personal health information will take all appropriate precautions to protect my personal health information from improper disclosure or use. I hereby consent to's transmission of my personal health information by electronic means.

If I was directed to's services through an affiliate, intermediary or other healthcare service provider Herein called an "intermediary") I hereby authorize to release the following data to such intermediary: a numerical identifier indicating that I was a patient referred from that intermediary; financial information that will permit the processing of any claims on my behalf;

It is my understanding that all such intermediaries will enter into confidentiality agreements where they will agree to abide by the privacy policies of relating to the protection of my personal health information. I specifically consent to the transmission of the forgoing information by electronic means.

I authorize and appoint as my agent and attorney for the purpose of taking all steps and signing all documents on my behalf necessary to package or re-package the pharmaceutical(s) and to deliver them to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.

I authorize and appoint as my agent and my attorney for the purpose of taking all steps and signing all documents on my behalf necessary for shipping my prescribed pharmaceuticals to me as if I had shipped them myself to my own address.

I understand that is located in Canada, not in the United States. I also acknowledge that the pharmacists working for and the physicians contracted by on my behalf are located and licensed to practice medicine or pharmacy in Canada and that all services that I receive from the Canadian pharmacy and the pharmacist are being received in Canada.

I further agree that any and all agreements reached or contracts formed throughout the course of the relationship between me and shall be deemed to be made in the Province of British Columbia, Canada and accordingly shall be governed by the laws of the Province of British Columbia, Canada and the laws of the Country of Canada.

I agree that any dispute that arises between me and, its affiliates, related companies, subsidiaries, parent company, officers, directors, employees, agents and contractors shall be governed by the laws of the Province of British Columbia and I agree that the courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such dispute.

If a problem arises, I understand that I may need to contact the College of Pharmacists for the Province of British Columbia located at 200 - 1765 West 8 th Avenue, Vancouver, British Columbia, Canada (Phone 604-733-2440 or 1-800-663-1940; Fax: 604-733-2440 or 1-800-377-8129) to report my concern.


I hereby acknowledge, understand, authorize and agree that: may charge my credit card account for the pharmaceutical(s) price(s) plus shipping (in US Dollars) as is posted on the web site on the date that completes my order.

In the event my payment is not authorized, I understand that has the right to cancel my order. In such event will attempt to provide me with notice of such cancellation. After an order has been sent to the pharmacy I may not cancel the order and the sale is final. The pharmaceutical(s) will be packaged in child protected packaging, unless requested otherwise by me on the Patient Questionnaire. shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available, unless the physician has indicated that there can be "no substitution" or dispensed as written. ONCE PURCHASED AND SHIPPED, NO PHARMACEUTICAL PRODUCT MAY BE RETURNED OR EXCHANGED. reserves the right to refuse to assist me in obtaining any order in its sole discretion, in which event I will be entitled to a refund for monies paid for such order. does not provide its agency or attorney services as a substitute for healthcare or the advice of My Doctor. will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the supplying pharmacy does not correspond with my prescription. shall not accept the return for use or re-use of any portion of any drug or non-prescription medication (British Columbia College of Pharmacists Bylaw 5 (33 subsection.1).

I have read and understood all of the terms and conditions set out in this Agreement for Services and agree, on behalf of myself, my heirs, successors, executors, administrators and assign to be bound by these terms and conditions.

Signed this ____ day of ________________________, 20____.


Print Name Clearly: ________________________________________


I provide my consent and authorize any physician, licensed in Canada and engaged by for the purposes set out herein, to obtain my full medical history, drug history, contact information and other necessary information and documentation from my U.S. physician. In this context, I further consent to both the Canadian physician and my U.S. physician contacting one another to discuss my medical condition and medical information and to release any such medical information to each other, as such may be necessary or appropriate to the prescribing of medication(s). I understand that the reason for this consent is to provide the Canadian physician with a full opportunity to conduct an independent analysis of whether the medications(s) prescribed by my U.S. physician is appropriate, and discuss any potential medical complications that may arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence.

I further agree to regularly visit my U.S. physician(s) and to promptly advise the Canadian physician of any changes to my medical condition or prescriptions.

I have read and understood the terms and conditions set out in this AUTHORIZATION TO CANADIAN DOCTOR above and I agree, on behalf of myself, my heirs, executors, administrators, successors and assign to be bound by these terms and conditions.

Signed this ____ day of ________________________, 20____.


Print Name Clearly: ________________________________________