Order Form

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Prescription Order Form
Thrifty Meds Now – 408 Main Street – Box 490 – Manitou, Manitoba, Canada, R0G 1G0.
Phone toll free: 1-866-999-7928  Fax toll free: 1-866-292-7217
First Name: _______________________ Initial: ___ Last Name: _______________________
Address: _________________________
City: _____________________ State: ____________________ Zip Code: ______________
Phone number: ________________________     Birth Date: _____ / _____ / _____  
Select payment method: Visa box Mastercard box AMEX box
Certified check
box Money Order box 
For the sake of security when your form is received you will be called for the credit card information if that was the payment method chosen.
Please fill out the order section below, if the order is under $100.00 add $10.00 for shipping.  If the order is $100.00 or higher shipping is free of charge.
Please indicate if you have never taken this medication before by placing an ‘N’ before the name of the medication.