| Name (For Pet medication(s) Please Enter
the Owner's Info!): ________________________________________
Address: ___________________________________________________________________________________
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: _______________
(Visa and MasterCard Only)
Cardholder's Address: ________________________________________________________________________
| ________________________ |
_______________________ |
__________ |
| CARDHOLDER'S NAME (print name) |
CARDHOLDER'S SIGNATURE |
DATE |
|
|
PATIENT AGREEMENT
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 contractors (including physicians and nurses, pharmacists
and pharmacy technicians) according to the Privacy Policy as posted on
GLC website which may be updated from time to time.
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.
GOVERNING LAW
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) |
PATIENT'S SIGNATURE |
DATE |
|