NAME OF MEDICATION, DOSE AND INDICATION (Reason for medication...ex...diabetes)
FOR MEDICATIONS AVAILABLE THROUGH PERSONAL IMPORTATION*...(Diabetes, HIV, COPD, Depression and Cardiovascular medications), please upload a prescription. WE NORMALLY PROVIDE A 3 MONTH SUPPLY OF THE MEDICATION. PLEASE ASK YOUR PROVIDER TO WRITE THE PRESCRIPTION FOR A 3 MONTH SUPPLY OF THE MEDICATION WITH THREE REFILLS. *Personal Importation - Your medication will come from a certified and licensed Canadian pharmacy.
AUTHORIZATION - IF THE PATIENT IS A DEPENDENT CHILD UNDER THE AGE OF 18
I confirm that she/he is being monitored by a a U.S. physician. I certify that the information provided regarding the dependent is accurate and true.
AUTHORIZATION - IF THE PATIENT IS THE EMPLOYEE, SPOUSE OR A DEPENDENT CHILD AGE 18 OR OLDER
I certify that the information provided by me is accurate and true.
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