Patient Mail / Fax Order Form

Fax to: 1-866-732-0306

Or mail to:

Purely Canadian Drugs
Suite #196, 7231 - 120th Street,
Delta, B.C.,
Canada V4C 6P5

Cover Sheet

Total Number of Pages (including this sheet)

Your Name: (as written on prescription)

1. Complete & sign the attached form

2. Fax toll-free 1-866-732-0306 (or mail) along with a copy of your original Prescription and a copy of a Picture ID or 2 of the following: birth certificate, passport, voter's card, marriage certificate, or military ID.

** Please note: if you order your prescriptions by mail, there is a $9.95 USD shipping fee ($15.95 USD for cold-pack items) per patient for an unlimited number of prescriptions. If you have subscribed to our Lifetime Shipping option, the $9.95 shipping fee will be waived. All prescriptions will be authorized for a 1-year period if indicated by the physician and will be honoured 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

Cart Details

Rx-

= Prescription Required Rx-

= No Prescription Required

Billing Address

First Name:

Last Name:

Address:

City / Town:

State / Province:

Zip / Postal Code:

Email:

Shipping Address