Canada Pharmacy Order Froms

Form 1 Authorization & Limited Power of Attorney Form I, THE UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY ENTER INTO This Authorization, Limited Power of Attorney and Release Agreement (the “Agreement”) with the Providers (as hereinafter defined) intending to be legally bound: 1. My Representations. I represent, acknowledge and confirm to QuadPharm Group Ltd.. (“QuadPharm”) 9. My Authorization to Transmit Personal Health Information Electronically. I acknowledge and it affiliates, related companies, subsidiaries and parent companies and the Licensed Referral and agree that I am aware that the Providers will be transmitting my personal health and Pharmacies (as hereinafter defined) (all of the foregoing hereinafter collectively referred to as the billing information by electronic means (for example fax, secure internet) to their respective employees, “Providers”) that (i) the pharmaceutical(s) to be delivered to me (“My Pharmaceutical(s)”) were agents, affiliates and services providers including the Engaged Physician retained on my behalf. I prescribed by my doctor (“My Physician”) who is licensed to practice medicine in the country, hereby consent to the Providers’ transmission of my personal health and billing information by state, or other applicable jurisdiction in which I reside; (ii) the prescription(s) for My electronic means. Pharmaceutical(s) (the “Prescription(s)”) were lawfully obtained by me from My Physician; (iii) My Pharmaceutical(s) will be used only as directed and only by the me as the person for whom My 10. No Child Protective Packaging Unless Requested and Related Release. I UNDERSTAND, Pharmaceutical(s) were prescribed; (iv) the Prescription(s) have not been altered in any way nor ACKNOWLEDGE AND DIRECT THAT MY PHARMACEUTICAL(S) WILL NOT BE PACKAGED IN have they been filled prior to submission to the Providers; and (v) I agree to immediately destroy all CHILD PROTECTIVE PACKAGING, UNLESS REQUESTED BY ME ON THE PATIENT copies of the Prescription(s) once they have been filled. ALLERGY/INTERACTION FORM, AND I RELEASE AND DISCHARGE THE PROVIDERS AND THEIR RESPECTIVE DIRECTORS, OFFICERS, SHAREHOLDERS, EMPLOYEES AND AGENTS 2. My Appointment of QuadPharm to Engage Licensed Referral Pharmacies. I understand, FROM ANY AND ALL CAUSES OF ACTION WHATSOEVER THAT MAY ARISE AS A RESULT AND authorize, agree and direct that QuadPharm as my agent and attorney being appointed as such I FURTHER RELEASE AND DISCHARGE THE PROVIDERS AND THE PROVIDERS’ pursuant to the appointment made by me below, may engage pharmacies licensed under DIRECTORS, OFFICERS, SHAREHOLDERS, EMPLOYEES AND AGENTS, FROM ANY AND applicable law in any one or more of Canada, the United States, the United Kingdom, New ALL CAUSES OF ACTION WITH RESPECT TO THE LATE DELIVERY, NON-DELIVERY OR Zealand, Australia, Israel, India, member countries of the European Union or elsewhere (such MISSED DELIVERY OF MY PHARMACEUTICAL(S) SENT TO ME. licensed pharmacies being collectively referred to herein as the “Licensed Referral Pharmacies” and individually as a “Licensed Referral Pharmacy”) to dispense any or all of My 11.Confirmation of My Initiation of Consultation and Acknowledgement of Location of Pharmaceutical(s) under the Prescription(s) and that QuadPharm may select one or more of the Dispensing. I understand, acknowledge and agree that I initiated a consultation with the Providers Licensed Referral Pharmacies to dispense My Pharmaceutical(s) and I hereby expressly appoint and that the Providers are not located in the United States. I further acknowledge that, to the extent QuadPharm as my agent and attorney to do so. I further understand, authorize, agree, and direct that My Pharmaceutical(s) are dispensed by one or more Licensed Referral Pharmacies in the country that any Licensed Referral Pharmacy may itself engage other Licensed Referral Pharmacies to in which any such Licensed Referral Pharmacy is located and that the pharmacists working for any dispense any or all of My Pharmaceutical(s) under the Prescription(s) as selected by such such Licensed Referral Pharmacies and the Engaged Physicians contracted on my behalf by any Licensed Referral Pharmacy with the consent of QuadPharm. In the event that I do not want my such Licensed Referral Pharmacy is located and licensed to practice medicine or pharmacy, as the Prescriptions dispensed by a particular Licensed Referral Pharmacy or from a particular country case may be, in the country in which any such Licensed Referral Pharmacy is located and that the in which an Licensed Referral Pharmacy may be located, I will provide notice in writing to service I am receiving from the said Engaged Physician and pharmacists is being received by me QuadPharm at the time of ordering instructing that my Prescription(s) be dispensed only by in the country in which any such Licensed Referral Pharmacy is located. Licensed Referral Pharmacies in the country or countries which I direct. 3. Shipping of Pharmaceutical(s) to Me. I understand that QuadPharm is itself not a pharmacy, and I further acknowledge and confirm that I have not sought or requested, nor am I seeking or requesting understand, authorize, agree and direct that My Pharmaceutical(s) be shipped directly to me by a medical opinion of any Engaged Physician regarding the strength, dosage, usefulness or qualities (and that I am purchasing My Pharmaceutical(s) from) the dispensing pharmacy, being a Licensed of the product ordered by me or the duration of use, frequency of use, or appropriateness for their Referral Pharmacy. I further acknowledge that if My Pharmaceutical(s) are purchased from, and particular medical condition, nor do I seek any medical advice in any way from the Engaged Physician. dispensed by more than one Licensed Referral Pharmacy, they will be shipped and arrive at my address separately. I FURTHER HOLD HARMLESS QUADPHARM, ITS OFFICERS, DIRECTORS, EMPLOYEES, AGENTS, AFFILIATES, RELATED COMPANIES, SUBSIDIARIES AND PARENT COMPANIES 4. Reliance by Providers on Information Provided by Me. I understand, acknowledge and agree FROM AND AGAINST ANY AND ALL SUITS, DEMANDS, LIABILITIES, CLAIMS, ACTIONS, that the Providers’ (including the Licensed Referral Pharmacies) and their respective employees EXPENSES, LOSSES, COSTS AND DAMAGES OF ANY KIND OR NATURE (I) ARISING FROM and agents have relied on and are and will be relying on the information and documentation provided ANY MATTER RELATED TO A LICENSED REFERRAL PHARMACY’S (OR ANY OF THEIR by me (including the information, representations, authorizations and confirmations provided in this RESPECTIVE OFFICERS', DIRECTORS' OR EMPLOYEES') NEGLIGENCE, BREACH OF ANY Agreement and in the Patient Allergy/Interaction Form that accompanies this Agreement) and I rep- LAW, REGULATION, RULE, ORDINANCE, OR ORDER OF ANY GOVERNMENT, COURT, TRIBUNAL, resent and confirm that I have, to the best of my knowledge, fully disclosed all pertinent requested GOVERNMENT BODY OR AGENCY OR PROFESSIONAL ASSOCIATION; OR (II) OTHERWISE information and documentation to the Providers (including the Licensed Referral Pharmacies). I undertake ARISING FROM A LICENSED REFERRAL PHARMACY FILLING MY PRESCRIPTION(S). to notify the Providers of any changes to my physical or medical condition by providing an updated Patient Allergy/Interaction Form upon any such change. 12.Governing Law and My Attornment to Courts in the Jurisdiction of the Dispensing Pharmacy. 5. My Obligation to Have Examinations. I understand and agree that it is my responsibility to I acknowledge, agree and confirm that any and all agreements reached or contracts formed have regular physical examinations by My Physician whose care I am under, including having and transactions undertaken with or involving any of the Providers throughout the course of all suggested testing by My Physician completed to ensure I do not have any medical problems my relationship with the Providers in respect of any of My Pharmaceutical(s) that were: which would constitute a contradiction to me taking My Pharmaceutical(s). (i) dispensed in Canada, are and shall be deemed to be made in the Province of Manitoba, Canada 6. My Appointment of Providers to Obtain Equivalent Prescription and My Medical Information. and shall be governed by the laws of the Province of Manitoba and the laws of Canada I authorize and appoint the Providers, as my agent and attorney for the limited purposes of taking applicable to such contracts, agreements and transactions and the courts of the Province of all steps and signing all documents on my behalf necessary to obtain an Equivalent Prescription Manitoba shall have sole and exclusive jurisdiction over any dispute that may arise between (as hereinafter defined) to the same extent as I could do if I were personally present taking those myself and the Providers in connection therewith or in relation thereto and I agree to attorn to steps and signing those documents myself, including, but not limited to, collecting my personal the courts of the Province of Manitoba for any and all such dispute or disputes; health information directly from My Physician or pharmacist and disclosing my personal health information to the employees, agents, contractors, subcontractors, affiliates and service providers (ii) dispensed in a country other than Canada are and shall be deemed to be made in, and (including without limitation, to any physicians engaged by the Providers to obtain an Equivalent shall be governed by the laws of such country applicable to such contracts, agreements Prescription (the “Engaged Physician(s)”) of the Providers, for the limited purpose set out above. I and transactions and the courts of that country shall have sole and exclusive jurisdiction understand and agree that, in this Agreement, the term “Equivalent Prescription” means a prescription over any dispute that arises between myself and any Provider whose principal office that is the equivalent to my Prescription(s) in the country in which the Licensed Referral Pharmacy is located in that country and I agree to attorn to the courts of such country for any and all located, as applicable. Without limiting any other provision of this Agreement, I hereby consent to such dispute or disputes. allow any Engaged Physician to obtain my medical history, drug history, contact information and other necessary documentation from My Physician. I understand that the Engaged Physician shall be a 13.Generics May be Substituted. I acknowledge, understand, authorize and agree that the Providers duly licensed physician in Canada if the Equivalent Prescriptions being obtained in Canada, or, if shall be entitled to substitute a prescription drug with a generic drug, where available unless the My applicable, a duly licensed physician in the country where the applicable Licensed Referral Pharmacy Physician has indicated that there be “no substitution” on the Prescription(s). is located, in the event that an Equivalent Prescription is necessary for the dispensing of My Pharmaceutical(s) by the Licensed Referral Pharmacy. 14.No Returns and Exchanges Once Shipped. I acknowledge, understand and agree that once 7. My Appointment of Providers for Repackaging and Delivery. I authorize and appoint the purchased and shipped, no pharmaceutical product may be returned or exchanged. Providers as my agent and attorney for the purpose of taking all steps and signing all documents on my behalf necessary to package or repackage My Pharmaceutical(s) and to deliver them to me, 15.Severability of Clauses and Headings For Convenience Only. I acknowledge and agree that in case any one or more of the provisions contained herein for any reason shall be held to be invalid, illegal, or to the same extent as I could do if I were personally present taking those steps and signing those unenforceable in any respect, such invalidity, illegality, or unenforceability shall not effect any other documents myself. provision of this Agreement, but this Agreement shall be construed as if such invalid, illegal, 8. Revocability by Me of Appointments and Authorizations. I acknowledge, confirm and agree that or unenforceable provision or provisions had never been contained herein. I further acknowledge and the authorizations, appointments, powers of representation and consents provided by me herein agree that the captions and headings used in this Agreement are for convenience of reference commence on the date hereof and continue until revoked by me. I understand that I can revoke only, and do not constitute a part of this Agreement and will not be deemed to limit, characterize the authorizations, appointments, powers of representation and consents granted hereby at or in any manner affect any provision of this Agreement, and all provisions of this Agreement any time by providing notice of writing of such revocation to QuadPharm. will be enforced and construed as if no caption or heading had been used in this Agreement. BY SIGNING THIS AGREEMENT, I CONFIRM THAT I HAVE READ AND UNDERSTAND THE FOREGOING TERMS AND I AGREE THAT THIS AGREEMENT IS AND SHALL BE BINDING UPON ME AND MY HEIRS, ASSIGNS, SUCCESSORS AND PERSONAL REPRESENTATIVES. Date Signed: Signature X Witness Signature: X Print Name: Print Name: (please print clearly) (please print clearly) (Photocopied Prescriptions must accompany all forms - faxed or mailed in) Fax: 1-800-563-3822 or Phone: 1-800-267-2688 or return by mail to: TotalDrugmart.com Order Processing, 210-900 St. James Street, Winnipeg, Manitoba R3G 3J7, Canada TotalDrugmart.com Toll Free Phone: 1.800.267.2688 Toll Free Fax: 1.800.563.3822 www.totaldrugmart.com

Form 2 Patient Information Patient Name: Date of Birth: Gender: M F Address: City State Zip Phone: (day) Phone: (eve) Email Address: Affiliate Code Medical Information Medical information needs to be submitted only on the first order or if medical condition changes. Known Drug Allergies Doctors Name, Address and Phone Number Current Medications Check box if you do not want child proof caps Medications Used in Past 12 Months Signature Date Order/Reorder Information Important: Please make money orders payable to: TotalDrugmart.com Promo Code NEW PATIENT or EXISTING PATIENT WEB Payment Method Visa Master Card Money Order Personal Check Credit Card # Expiry Date Name CVV Code (as it appears on check/card) Signature Date STRENGTH QUANTITY PRICE REQUESTED MEDICATION REQUESTED (U.S. DOLLARS) Brand Generics only permitted Subtotal $ TotalDrugmart.com Toll-Free Phone: 1-800-267-2688 Shipping $ 9.95 Order Processing Center Toll-Free Fax: 1-800-563-3822 210-900 St. James Street Email: info@totaldrugmart.com TOTAL (U.S. Dollars) $ Winnipeg, MB R3G 3J7 www.totaldrugmart.com REFERRED BY Full Name Phone Complete to receive $10 off for yourself and the person who referred you.

Canada Pharmacy Order Froms

by Total Drug Mart

Accessibility

Categories

Upload Details

Usage Rights

Statistics