Name as it appears on Credit Card

Credit Card Information

Is your credit card information on file correct? Yes No

Card Number
 Exp Month
 Exp Year

The medication you are seeking to purchase from The Canadian Drug Store has been prescribed for what condition?

HOW MANY MONTHS OF YOUR MEDICATION WOULD YOU LIKE AT THIS TIME?

1 MONTH............
2 MONTHS..........
3 MONTHS..........

Please indicate here if you prefer a generic version of your medication if one is available.
Yes No
 




Please attach your prescription for easy faxing


Customer ID# ______________________
Toll-free Phone # 1-888-372-2252
Toll-free Fax # 1-888-575-5506 or 416-946-1617

   

Mailing Address:

TCDS
1696 Avenue Road
Toronto, Ontario
Canada M5M 3Y4