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Print these pages. Remember to sign and date where required. 
e will require certain information from you which includes:

Signed Patient Agreement
(printout included in this information package)
2) Patient Medical Information and Order Forms
(printouts included)
3) Your prescription(s)

Note: If you do not have a copy of your prescription, we will need your physician’s name, phone and fax number so that we may contact him
to receive a copy of the prescription

You may place your order using the 2-step process listed below.  
A representative can check the cost of your prescription, or you may
search our
online database
online database for pricing.     

Step 1.   Complete and Sign the:

a.  Patient Medical Information Form
b.  Patient Agreement
c.  Order Form

Step 2.   Send us your order: There are three ways to send in your order

a.  Fax the signed forms and your prescription to our 
toll free fax number 1-877-807-4831

b.  Mail the signed forms and the original prescription to us.
c.  Mail or fax the signed forms and have your doctor fax us copy of your prescription.

Currently we are unable to transfer prescriptions from other pharmacies.
     It will take at least two weeks for your order to arrive after we receive the forms. 
        There is a flat $13.99 shipping fee per package (not per drug).

Mail To:  
    1412 Berkshire Dr.
  Austin, TX 78723
 Toll Free Phone: 1-877-807-4831



No prescription will be filled until a signed and dated copy of this document and a completed Patient Questionnaire has been received by Norphar. These documents can be sent by fax toll free to 1-877-807-4831, or mailed to address above.
This completed Patient Agreement must be delivered to North American Pharmacy Network (operating as Norphar, or Norphar Network) by any patient seeking to have Norphar and one of it's associated pharmacies fill a prescription which has been issued by a non-Canadian physician.

Patient Agreement  

By signing this Agreement below, I agree that:

1.         Under Canadian law, Norphar and its associated pharmacies cannot fill my prescription request until a licensed Canadian physician (the "Canadian Physician") reviews my medical information and makes an independent judgment regarding the medications prescribed by my personal physician (“My Local Physician”).
2.         The  Canadian Physician is not rendering or providing any service or advice to me by reviewing my medical information. It is my responsibility to have My Local Physician conduct regular physical examinations of me, including testing suggested by My Local Physician, to ensure that I have no medical problems which would constitute a contraindication to my use of  medications prescribed by My Local Physician. If I suffer any adverse affects while taking any prescription medication, I will immediately contact My Local Physician.  If I come under the care of another physician, I will inform him or her of all medications that have been prescribed for me. I acknowledge that Norphar and it's associated pharmacies recommends regular physician examinations with My Local Physician whose care I am under and who initially prescribed my medications.
3.         I hereby give permission to My Local Physician to release all medical information and data requested by Norphar for the purpose of reviewing my medical information. I understand that this will include reviewing my Patient Medical Information Form and any information submitted by My Local Physician.
4.         I understand that information provided to Norpharand it's associated pharmacies may be seen by its employees, agents and contractors and that this information will constitute a medical record.
5.         I understand that Norpharand it's associated pharmacies will only verify and prescribe medications that My Local Physician has already prescribed to me. The Canadian Physician cannot prescribe any additional medications.  I understand that the Canadian Physician will not approve any controlled medications, narcotics, tranquilizers, or other medications that he or she determines not to be appropriate.
6.         I waive any requirement that the Canadian Physician examine me physically.
7.         The  review of my medical information by the Canadian Physician is in no way intended as a means to diagnose any medical condition and is no substitute for obtaining my own professional medical advice from My Local Physician. I agree to a direct all medical questions to My Local Physician. I will consult My Local Physician before taking any new medication or changing my daily health regimen.  Any opinions, advice, statements, services, offers or other information expressed or made available by third parties (including merchants and licensors) are those of the respective authors or distributors.  
8.         I confirm that I am twenty one years of age or older and that I am competent to make my own health care decisions. I am aware of the potential side effects and problems associated with prescription medications and understand that I would be violating law if I falsify any information on my Patient Medical Information Form or other medical records for the purposes of obtaining prescription medication.
9.         I agree to answer all questions on Patient Medical Information Form truthfully and to the best of my knowledge. I agree that if I fail in any way to furnish my complete and accurate medical history, and do not correct such failure, I am solely responsible for any adverse effects that I may suffer from taking or continuing to take medications supplied by Norphar.  I agree that I will notify Norphar of any changes in my physical or medical condition, and if I fail to notify Norphar of such changes, I am solely responsible for any adverse effects that I may suffer from taking or continuing to take medications supplied by Norphar.
10.       I certify that I have had a physical examination by My Local Physician within the last 12 months.
11.       Norphar provides administrative and marketing services to Canadian pharmacies engaged in filling prescriptions for individuals residing in the United States. I acknowledge and agree that Norphar does not provide any clinical or dispensing services and that it has no liability with respect to the appropriateness, suitability, strength or dosages of the medications prescribed or dispensed to me, including without limitation, any dispensing errors or side effects or ill effects of any kind.
12.       Due to the nature of prescription medications and requirements of Canadian and U.S. law, medications are not returnable. All sales are final.
13.       I acknowledge and agree that I am not relying on Norphar with respect to the dispensing of prescribed medications other than to forward the prescription to the dispensing pharmacy. Any disputes regarding the dispensing, shipping or other matters relating to the prescription are exclusively between me and the Canadian pharmacy whose name and address appears on the prescription container.


SIGNATURE __________________________________     DATE ____________________

Referral Program:

We are now offering additional discounts for referrals. If you are responding as a referral from someone, please fill out the following so they may receive their discount:

The Name of the person that referred you:   ______________________________________

Their address and/or phone number:            ______________________________________










Patient Medical Information Form (Please Print)

                                                Have you filled out this form before?  Yes ___     No___  
Your Personal Information
Name: ____________________________________
Street Address: ______________________________________________
Address (cont.): ______________________________________________
City: ____________________________ State/Province _______ Zip Code:_________
Work Phone: ____________________ Home Phone:__________________
E-mail: ______________________________
Date of Birth: _________________ Sex: __________ Height_______Weight_________

You MUST answer ALL of the following QUESTIONS for your order to be FILLED.
Have you had a physical examination by a qualified medical
doctor in the last 12 months?  Yes ___       No ___
(Note: This is mandatory in order to have a Canadian physician countersign your prescription)

Personal Medical Information

Do you have a history of or any early findings suggestive of the following?

Condition Yes No Please describe
Blood Disorders: (sickle cell, G6PD, platelet disorders, blood clots in legs or lungs )      
Immune Disorders
(HIV or ARC)
Gastrointestinal tract disorders
(Peptic Ulcers, Esophageal Reflux, Colitis, Crohns, Celiac Disease, Diverticulits, Pancreatitis)
Neurological disorders
(epilepsy, stroke, TIA, migraines, parkinsons, multiple sclerosis)
Endocrine disease: (Diabetes, thyroid disease, adrenal disease either cushings or addisons)      
Lung Disorders
(Asthma, COPD, emphysema)
Lipid or Cholesterol disorder      
Heart Disease: (Heart failure, angina, MI, pacemaker, atrial fibrillation, ventricular arrhythmia)      
Renal or Kidney Disease: (Renal failure, renal artery stenosis, glomerulonephritis, nephrotic syndrome, kidney stones)      
Liver Disease: (Infectious hepatitis, hemochromatosis, cirrhosis)      
Orthopedic or muscle disease      
Emotional Disorders: (Major Depression, Schizophrenia, ADHD, anorexia bulimia, hospitalization for above)      
Allergies To Drugs & Other      
Past Hospitalization or Surgery
(Including transplant surgery)
Lifestyle Risk: (smoking, alcohol, overweight, OTC diet pills, chronic pain medications)      

Please tell us about any illness or medical condition you have not listed above:

Please List all Allergies (Drug and Other): __________________________________
Please list all current medications. (Include over-the-counter medications and Herbal Medications)













I confirm that all information provided is true and correct to the best of my knowledge. I give Norphar permission to contact my physician to request additional medical information.  I consent to release of requested additional medical information by my physician..


Patient Signature: _____________________________   Date: ____________________  



Order Form
(Please Print)

Your Family Physician Information:
(Please provide information for your Primary Physician)
Doctor's Name: ____________________________________
Street Address: ______________________________________________
Address (cont.): ______________________________________________
City: ____________________________ State/Province _______
Zip Code: ____________
Work Phone: ____________________       Fax number: __________________

Your Order
(Faxed by Doctor's Office or Mailed)  
Would you like to speak with a pharmacist?  Yes__  No__

Medication Ordered

Brand or Generic Dosage  


Price Quoted


































Visa ___        MasterCard ___      Money Order ___      Check ___      

Name as appears on Card: __________________________________________________

Credit Card # : ______________________________________________ Exp:_________

Have you had this medication before  Yes ___        No ___

Signature: _______________________________________Date: _______________