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1. ENTER YOUR PERSONAL DETAILS - THIS FORM IS FOR OVER THE COUNTER ORDERS ONLY

First Name

Middle Name

Last Name

Your Gender
Male Female

Your Birth Date
Month Day Year

Your Weight

in Pounds

2. ENTER YOUR CONTACT INFORMATION AT YOUR PRIMARY ADDRESS

Street

City/Town

State

Zip Code

Country

Phone (Home)

Phone (Office)

(optional)

Phone (Cell)

(optional)

Fax

(optional)

Email

3. ENTER YOUR CONTACT INFORMATION AT YOUR ALTERNATE ADDRESS IF APPLICABLE

Street

City/Town

State

Zip Code

Country

Phone (Home)

4. ENTER YOUR SHIPPING PREFERENCE

Where would you like this order shipped ?

Primary Address Alternate Address

Please provide any other shipping information ?

(optional)

5. ORDER FORM

Medication Name

Strength

Directions for use

How long have you been taking this med?

Quantity Requested

Order this Medicine
Yes or No

Example - Synvisc

3 x 2ml

every 10-12 weeks

1 year

3 Vials

YES

Your initial order for each prescription will be delivered between 10 and 14 days in most cases. All refills should be delivered in approximately 10 days.

6. READ OUR RETURN POLICY

All sales are final. Be sure you order accurately to prevent problems. The law states:
"A pharmacist shall not accept for return to inventory any drug that has been previously dispensed"

Pharmaceutical Act Section 23(1) Return Medication (1)

I have read and understand the information above:

Yes No

7. ENTER YOUR BILLING INFORMATION

Cardholder's Name

Credit Card Type

Credit Card Number

Expiration Date

Month

Year

** You will be charged in US Dollars **

We do accept Money Orders & Personal Checks - Please make payable to Glenway Pharmacy
A Representative will call you to confirm your order after successfully completing your order forms

If You have any questions, please call toll free 1-866-712-4448