Name (For Pet medication(s) Please Enter the Owner's Info!): ________________________________________
City: ________________________ State: _________ Zip: ____________ Employer or a Group ____________
Tel # (Day): __________________________________ Tel # (Night) :_________________________________
Date of Birth: ______________________ Sex: _______ Weight: ________
How did you hear about us?_______________________________ E-mail: ______________________________
Do you have any allergies (including drug allergies)? _____ If Yes please list: ___________________________
Please list all medications you are currently taking here: ____________________________________________
Please Circle Any Medical Conditions that apply to you: Blood Disorders, Cancer, Immune disorders, Poor wound Healing, Neurological disorders, Diabetes, thyroid, or other endocrine disorders, Nutritional deficiency, Lipid or
cholesterol disorder, Heart disease, Renal or kidney disease, Liver Disease, Orthopedic or Muscle disorders, Emotional disorders, Glaucoma.
If you circled any of above, please elaborate here:
PRESCRIBING PHYSICIAN INFORMATION: Name: _____________________________________________
Address: ________________________________________________________ DEA#: ____________________
City: _______________________________________ State: _______ Zip: ___________ Tel: ______________
CREDIT CARD BILLING INFORMATION:
Credit Card # ____________________________ Exp. Date: __________ Cardholder's Tel: _______________
Cardholder's Address: ________________________________________________________________________
|CARDHOLDER'S NAME (print name)
BY SIGNING BELOW I CONFIRM THAT:
- IF PLACING THIS ORDER AS A CUSTOMER, I, ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS AND SUCCESSORS, HEREBY AGREE TO ALL OF THE FOLLOWING TERMS AND CONDITIONS, REPRESENT THAT I UNDERSTAND ALL OF THE FOLLOWING TERMS AND CONDITIONS AND THAT I HAVE
HAD ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.
- IF I AM PLACING THE ORDER ON BEHALF OF SOMEONE ELSE, I REPRESENT THAT I HAVE ALL NECESSARY CONSENT, PERMISSION AND AUTHORIZATION TO DO SO ON BEHALF OF THAT PERSON AND THEIR HEIRS, ASSIGNS AND SUCCESSORS AND THE PERSON I REPRESENT AGREES TO
ALL OF THE FOLLOWING TERMS AND CONDITIONS, UNDERSTANDS ALL OF THE FOLLOWING TERMS AND CONDITIONS AND HAS HAD AN ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.
AUTHORIZATION AND CONSENT
I hereby appoint Global Care, Ltd. (GLC) and its partnered Canadian Pharmacy (“Pharmacy) as my agent and attorney for the purposes of obtaining a prescription from a Medical Doctor in Canada (the "Canadian MD") which corresponds to the
prescription included in this order, which may include directly contacting my prescribing physician, and purchasing and arranging delivery of the medications prescribed in the Canadian prescription, substantially on the terms set forth below, all
to the same extent I could if I personally took such steps. I hereby consent to GLC, the Canadian MD and any Pharmacy supplying my order, collecting my personal and medical information, maintaining the information necessary to quickly process
future orders which may include retaining on file my name, address, phone number, payment and other information and verifying future orders. I confirm that my personal information will be handled only GLC’s order-processing employees and
DISCLOSURE AND REPRESENTATIONS
I represent that all of the following statements are true and agree GLC and its contractors (physicians and nurses, pharmacists and pharmacy technicians) are relying on these representations:
- I am of the age of majority or older where I reside;
- I can make my own medical decisions according to the law of the place I reside;
- The prescription I am requesting GLC to assist me in obtaining was prescribed by a qualified physician licensed where I obtained the prescription;
- The prescription I am requesting GLC to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to GLC. I agree to immediately destroy all copies of my prescription once it has been filled;
- I am not violating any laws where I reside by placing this order;
- I will use any medication obtained for me by GLC strictly according to the instructions provided by the physician who prescribed the medication;
- I am placing this order for medication for my sole use and I will not provide any quantity of this medication to any other person;
- I am not seeking or relying on any medical information from GLC and I have consulted a qualified physician licensed where I obtained the prescription within the last year; and
- I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me GLC. GLC has made no representations or warranties to me,
including, without limitation, representations or warranties with respect to any delivered medications' usefulness or fitness for a particular purpose (including, without limitation, its appropriateness for curing or helping relieve any
particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown).
PURCHASE AND SALE TERMS
Pharmacy will charge my credit card the following amounts: the medication price (in U.S. dollars) and shipping fee as posted on the GLC’s Website on the day GLC receives my order. In the event my payment is not authorized, GLC has the right to
cancel my order and attempt to provide me with notice of such cancellation. GLC reserves the right to refuse to assist me in obtaining any order in its sole discretion, in which event I will be entitled to a refund for monies paid for such order.
GLC does not provide its agent or attorney services as a substitute for health care or the advice of a physician. GLC will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the
supplying pharmacy does not correspond with my prescription. Pharmacy will charge the customer's credit card or withhold money from any refund due to the customer in an amount equal to GLC's shipping charge and a 15% restocking fee for all
unauthorized returns or for any packages returned due to customer's refusal of shipment. The 15% restocking fee is calculated on the cost of the order not including shipping. All prices quoted on the web site are subject to change without notice.
GLC will not honor any typographical errors concerning price, strength, dosage, or any other information concerning the quoted medication(s).
RELEASE AND WAIVER
I hereby release and discharges GLC and its employees, officers, agents, representatives and contractors (including physicians and nurses, pharmacists and pharmacy technicians) harmless from any and all suits, demands, liabilities, claims,
actions, expenses, losses and damages of any kind or nature whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation (including reasonable attorney fees) arising from:
- My use of the medication obtained for me by GLC including, without limitation, any and all side effects whether previously known or unknown;
- GLC's or its contractors' manner or timeliness of completing any actions I have authorized above, including, without limitation, their manner or timeliness in prescribing the appropriate strength, dosage, or dispensing generic drugs and
non-child-protective packaging; and
- My breach of any terms, conditions or representations or warranties in this agreement. Nothing in this release shall be deemed to release any Pharmacy or pharmacist contractors from compliance with the applicable standards of practice or
usual professional duties and obligations, which a pharmacist owes.
This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of the province in which the Pharmacy is located. I have read and understood all of the foregoing terms and conditions.
|PATIENT'S NAME (print name)