Affordable RX Canadian Pharmacy - Affordable Prescription Drugs from Canada
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Refills
 

If you are an Affordable RX customer, and have previously ordered from us - please fill in the form below and click Submit. If you prefer, please feel free to call in your refill request at toll free .

If you have never ordered from our pharmacy network before, please do not attempt to use this form to place your order. Please see our How To Order page for instructions on placing your first order.

The form could not be submitted because it contains errors...
(required fields are indiciated with an asterisk (*)
 
Full Name:  *
Email:  *
Phone:  *
Shipping Address:  *
City:  *
State:  *
Zip Code:  *
Order includes new prescription:
New address or phone number:
Medication:
Strength:
(eg.: 10 mg/ml)
Quantity:
(eg.: number of tablets or capsules)
Allow Generic Substitution?
Medication:
Strength:
(eg.: 10 mg/ml)
Quantity:
(eg.: number of tablets or capsules)
Allow Generic Substitution?
Medication:
Strength:
(eg.: 10 mg/ml)
Quantity:
(eg.: number of tablets or capsules)
Allow Generic Substitution?
Medication:
Strength:
(eg.: 10 mg/ml)
Quantity:
(eg.: number of tablets or capsules)
Allow Generic Substitution?
Medication:
Strength:
(eg.: 10 mg/ml)
Quantity:
(eg.: number of tablets or capsules)
Allow Generic Substitution?

On February 1st, 2014 we were required to have all customers sign off on a new Patient Agreement in order to comply with new Pharmaceutical Association regulations. Please review the terms below and sign in order to help us complete your order.

Affordable RX which includes its officers, directors, affiliates, representatives, agents, contractors and sub-contractors (collectively, “Affordable RX ”) is an international prescription referral service committed to helping ensure that I, the undersigned patient (“I” or “Me”), am able to obtain medication, products and /or services (“Product”) from licensed pharmacies. This Patient Authorization Agreement (“Agreement”) shall govern all sales of Product facilitated by Affordable RX between me and any of Affordable RX authorized pharmacies located in Canada, the United Kingdom, India, Singapore, Turkey, Vanuatu, USA, and elsewhere (collectively, the “Pharmacy”). I acknowledge and agree as follows:

  1. I am the age of majority, am fully competent to make my own health care decisions and have obtained any prescription(s) for the Product in a lawful manner.
  2. I must have been taking the prescribed medication for a minimum period of thirty (30) days immediately prior to the date that I submit my prescription to Affordable RX for filling.
  3. I understand that it is my responsibility to have my prescribing physician (“My Own Physician”) conduct regular physical examinations, including any and all suggested testing to ensure that I have no medical problems which would constitute a contraindication to me taking the Product. I certify that I have had a physical examination by My Own Physician within the last two (2) months from the date hereof.
  4. I agree that if I suffer any adverse effects while taking any prescription medication that I will immediately contact My Own Physician and that in the event that I come under the care of another physician, I will inform him or her of any and all medications that I have been prescribed. I further acknowledge and agree that Affordable RX recommends regular physician examinations with My Own Physician whose care I am under and who initially prescribed my medications.
  5. I agree and understand that it would be a violation of the law to falsify any information provided to Affordable RX, including, but not limited to, any information on the Affordable RX Order Form (“Order Form”). I agree to truthfully, and to the best of my knowledge, answer all of the questions on the Order Form. I further agree and understand that I will be solely responsible for any adverse effects that I may suffer from taking or continuing to take the Product in the event that I have failed to fully furnish my complete and accurate medical history and/or if I fail to notify My Own Physician and Affordable RX of any change in my physical or medical condition.
  6. I further understand that Affordable RX will only verify and provide Product that My Own Physician has already prescribed to me. No new prescription medications will be provided by Affordable RX. I also understand that no controlled medications, narcotics, tranquilizers, or other medications that Affordable RX decides are inappropriate, will be provided.
  7. I appoint Affordable RX to act as my agent and attorney in order to take all steps that it deems necessary to have the Product dispensed by the Pharmacy, to the same extent as I could do if I were personally present at the Pharmacy, including: (a) collecting personal health information about me; (b) disclosing that information to and having a licensed physician perform an independent medical review in order to obtain a valid prescription for the Product; and (c) packaging the Product and delivering it to me. I hereby waive any requirement of the physician to conduct a physical examination. This authorization may be revoked by me at any time and shall continue until such revocation has been provided to Affordable RX, in writing.
  8. There will be no additional fees charged to me in the event that an independent medical review is required to obtain a valid prescription for the Product.
  9. I initiated contact with and understand that Affordable RX is not located in the United States.
  10. The Product is sold and dispensed by the Pharmacy in accordance with the laws of the jurisdiction in which the Pharmacy is located. Title to the Product passes from the Pharmacy to me when the Product leaves the Pharmacy. The Pharmacy delivers the medication to my agent in the IPS’s jurisdiction. Typically this agent is a delivery service, in which case I give the Pharmacy or its agent authority to select the agent on my behalf.
  11. Any and all physicians and/or pharmacists (“Providers”) retained by Affordable RX in order to obtain the Product from the Pharmacy are located and licensed to practice in the jurisdiction in which they are located. Any treatment that I receive from the Providers shall be deemed to be received by me in the jurisdiction in which the Providers are located.
  12. I understand and agree that the review of my medical information by a physician is in no way intended as a means to diagnose any medical condition and does not substitute the requirement for me to obtain my own professional medical advice from My Own Physician. I agree to a direct all questions to My Own Physician. I will consult My Own Physician before taking any new drug or changing my daily health regimen.
  13. Any and all agreements reached or contracts formed and transactions undertaken with or involving the Pharmacy are and shall be deemed to be
  14. made in the jurisdiction of the Pharmacy and shall be governed by the laws of the jurisdiction of the Pharmacy applicable to such contracts, agreements and transactions(unless Affordable RX elects otherwise in its sole discretion) . The Courts of that jurisdiction shall have sole and exclusive jurisdiction over any dispute that may arise between me and the Pharmacy and I agree to attorn to the Courts of that jurisdiction for any and all such dispute or disputes (unless Affordable RX elects otherwise in its sole discretion).
  15. Affordable RX may communicate with me via email or telephone to discuss my order or pending refill order for the Product.
  16. Not all of the services or products shown on Affordable RX website are available in all jurisdictions.
  17. I acknowledge that the terms and conditions as found in this Agreement are readily available to me on a 24-hour basis from Affordable RX website and acknowledge having had every opportunity to obtain independent legal advice with respect to this Agreement.

“I have read and understand the forgoing terms and I agree that they shall be binding upon me and my heirs, assigns, successors and personal representatives.”
OR
“I am the parent/legal guardian/power of attorney for the customer disclosed herein, am over the age of majority, and have full authority to sign for and provide the above representations to Affordable Rx on the customer’s behalf.”


Draw your signature
 
Please answer: 7 + 7 =

Thank you, the refill order will go for processing. Please be sure all of the information above is correct. A representative will contact you only if necessary. Please allow up to 21 days for the delivery of your order.

We will use the payment information that we have in your file. If there has been a change in your payment information, please call our toll free number .

DISCLAIMER: Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. You should read carefully all product packaging. Not all Canadian drugs, Canada prescription and Canadian prescription medicine is available from our discount referral service. If you have or suspect that you have a medical problem, promptly contact your health care provider. Information and statements regarding diet supplements have not been evaluated by Health Canada and are not intended to diagnose, treat, cure, or prevent any disease. All trade and service marks mentioned on this site are recognized as belonging to their respective owners.

FDA, due to the current state of their regulations, has taken the position that virtually all shipments of prescription drugs imported from a Canadian pharmacy by a U.S. consumer will violate the law.

Affordable RX™ - "Your Prescription for Savings" ®