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To sign up and receive all of The Canadian Pharmacy special offers and drug prices
please fill out the form below.
Remember you do not need a credit card or any other form of payment to sign up.

Welcome, Sign Up for Discount Prescriptions Here:

Affiliate ID #:		(if you are not an affiliate start at First name and continue)
First name:		Last name:
Date of Birth:	(4 digit year, ie: 1968)	Sex:	M F

Shipping Address:
City:		State:
Zip Code:
E-mail:		Telephone:	(include area code, no spaces, '()' or '-')

Known allergies:		Other Medications you are currently taking:

Patient Counseling :	I understand my medication and do not need to speak to a pharmacist or receive information sheets.
	I do require medications information sheets only.
	I would like to speak to a pharmacist about my medications.

	A pharmacist may contact you with any questions regarding your medication

Medical History:

1) Heart Condition or Blood Pressure:
Yes No

Angina		Arrhythmia
Congestive Heart Failure		Stroke
Atrial Fibrillation		Hight Blood Pressure
Mitral Valve Disease		Heart Attacks
Other (indicate):

7) Kidney or Liver Disorder:
Yes No

Renal (kidney) Failure		Require Dialysis
Hepatitis		Cirrhosis of the Liver
Other (indicate):

2) Gastrointestinal:
Yes No

Acid Reflux/GERID		Hiatal Hernia
Irritable Bowel Syndrome		Chron's Disease
Rectal Bleeding/Black Stools		Stomach Ulcers
Lactose Intolerance		Ulcerative Colitis
Other (indicate):

8) Colon or Prostrate Disease:
Yes No

Benign Prostrate Hypertrophy (BPH)		Colon Disorder
Other (indicate):

3) Diabetes, Thyroid, Endocrine Condition:
Yes No

Type 1 Diabetes		Type 2 Diabetes
Hypoglycemia		Thyroid Disease
Hyperthyroidism		Hypothyroidism
Other (indicate):

9) Chronic Illness:
Yes No

Chronic Fatigue Syndrome		Chronic Pain
Multiple Sclerosis		Fibromyalgia
Other (indicate):

4) Neurological or Psychological:
Yes No

Anxiety		Depression
Bipolar Disorder		Attention Deficit Disorder
Epilepsy		Migraines
Panic Disorder		Parkinson's
Other (indicate):

10) Muscle, Bone, or Joint Disorders:
Yes No

Arthritis		Gout
Osteoporosis		Back/Spine Disorders
Other (indicate):

5) Eye Disorders:

Yes No

Glaucoma		Cataracts
Retinal Problems
Other (indicate):

11) High Cholesterol:
Yes No

If yes, diagnosed at what age?
High Triglycerides		Lipids

Other (indicate):

6) Respiratory Condition:
Yes No

Allergic Rhinitis		Asthma
Emphysema		Chronic Bronchitis
Other (indicate):

12) Other medical Conditions:
Yes No

Acne		AIDS
Anemia		Menopause
Sleeping Disorder		Obesity
Blood Disorders		Eczema/Psoriasis
Smoking		Pregnancy
Cigarettes per day for years
Cigarettes per week for years

Other (indicate):

13) Cancer: Yes No

If yes, please specify type: