Phone: 1-877-592-9192     Fax: 1-877-737-3517    1915 Trade Center Way, Naples, FL USA 34109
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This option is available to patients that have previously ordered form us. Please also be sure to inform us of any changes to your health profile, billing preferences or contact information.

First Name
Shipping Address
Last Name
City
Phone Number
State
Email Address
Zip Code

 

Informed Consent for Patient Counselling
All patients receiving prescriptions from our pharmacy have the right to receive counselling from a licensed pharmacist.
Would you like a pharmacist to call and discuss your order with you?
Yes     No
Are you sending a new prescription to be processed with this order? 
Yes     No  
Did your mailing address or telephone number changed since the last order?
Yes     No   (if yes, please specify above)

 

Refills Requested
*Fields required to be filled for your request.
 
*Medication Name As on prescription label Drug Strength
e.g. 10 mg/ml
*Quantity
Number of tablets capsules, mls, etc.
Generic
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.

Online Pharmacy Direct which includes its officers, directors, affiliates, representatives, agents, contractors and sub-contractors (collectively, “Online Pharmacy Direct ”) 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 Online Pharmacy Direct between me and any of Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct, including, but not limited to, any information on the Online Pharmacy Direct 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 Online Pharmacy Direct of any change in my physical or medical condition.
  6. I further understand that Online Pharmacy Direct will only verify and provide Product that My Own Physician has already prescribed to me. No new prescription medications will be provided by Online Pharmacy Direct. I also understand that no controlled medications, narcotics, tranquilizers, or other medications that Online Pharmacy Direct decides are inappropriate, will be provided.
  7. I appoint Online Pharmacy Direct 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 Online Pharmacy Direct, 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 Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct elects otherwise in its sole discretion).
  15. Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct 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 Online Pharmacy Direct on the customer’s behalf.”

Draw your signature:

 

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