No prescription will be filled until a signed and dated copy of this document and a completed Patient's Health Profile has been received by RxmedsCanada. These documents can be sent by fax to (403) 238 0858.

THE UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY:

1. Represents and confirms to RxmedsCanada, and RxMedsCanada.com, its affiliates, related companies, subsidiaries and parent company (hereinafter “RxmedsCanada”) that the pharmaceutical(s) to be delivered to the undersigned were prescribed by a doctor licensed to practice medicine in the country, state, or other applicable jurisdiction in which the undersigned resides, that the prescription(s) for the pharmaceutical(s) were lawfully obtained from that physician and that the pharmaceutical(s) will be used only as directed and only by the person for whom the pharmaceutical was prescribed.

2. Acknowledges that RxmedsCanada and RxmedsCanada’ employees and agents have relied on the information and documentation provided by the undersigned (including the Patient's Health Profile) and the undersigned represents and confirms that the undersigned has, to the best of his/her knowledge, fully disclosed all pertinent requested information and documentation to RxmedsCanada. The undersigned undertakes to notify RxmedsCanada of any changes to his/her physical or medical condition by providing an updated Patient's Health Profile.

3. Understands that it is the undersigned’s responsibility to have regular physical examinations by the U.S. licensed physician whose care he/she is under, including all suggested testing by said physician to ensure the undersigned has no medical problems which would constitute a contradiction to him/her taking the medications being prescribed.

4. Authorizes and appoints RxmedsCanada, as his/her agent and his/her attorney for the limited purposes of taking all steps and signing all documents on behalf of the undersigned necessary to obtain a prescription in Canada for the prescription sent by the undersigned to RxmedsCanada, to the same extent as the

undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself, including, but not limited to, collecting personal health information regarding the undersigned directly from his/her prescribing physician or pharmacist and disclosing personal health information to RxmedsCanada’ employees, agents and service providers, as required, for the limited purpose set out above.

5. Authorizes and appoints RxmedsCanada as his/her agent and his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned necessary to package or repackage the pharmaceutical(s) and to deliver them to the undersigned, to the same extent as the undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself.

6. Authorizes and appoints RxmedsCanada, as his/her agent and as his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned necessary for shipping his/her prescribed pharmaceutical(s) to the undersigned as if the undersigned had shipped the prescribed pharmaceutical(s) to himself/herself to the undersigned’s address.

7. Understands and acknowledges that the pharmaceutical(s) will not be packaged in child protective packaging, unless requested by the undersigned on the Patient's Health Profile, and the undersigned releases and discharges RxmedsCanada and RxmedsCanada’ employees and agents, from any and all causes of action with respect to the late delivery, non-delivery or missed delivery of the pharmaceutical(s) sent to the undersigned.

8. Acknowledges and agrees that the undersigned initiated a consultation with RxmedsCanada and that RxmedsCanada is not located in the United States. The undersigned acknowledges that the pharmacists working for RxmedsCanada and the physicians contracted by RxmedsCanada on the undersigned’s behalf are located and licensed to practice medicine or pharmacy in Canada and that all treatment the undersigned is receiving from the said physician and pharmacist is being received in Canada.

9. Acknowledges and agrees that any and all agreements reached or contracts formed throughout the course of the relationship between the undersigned and RxmedsCanada shall be deemed to be made in Alberta, and accordingly shall be governed by the laws of the Province of Alberta and the laws of Canada as applicable to such contracts and agreements.

10. Agrees that any dispute that arises between him/her and RxmedsCanada, its affiliates, related companies, subsidiaries, parent company, officers, directors, employees or agents shall be governed by the laws of the Province of Alberta and the laws of Canada applicable to contracts formed in Alberta and the undersigned agrees that the Courts of the Province of Alberta shall have sole and exclusive jurisdiction over any such dispute. 

11. Understands that RxmedsCanada shall be entitled to substitute a prescription drug with a generic drug, where available in accordance with the Alberta Drug Standards and Therapeutic Formulary, unless the physician has indicated that there be “no substitution”.

12. Understand that the prescription(s) requesting from Rxmedscanada , has not been altered in any way, has not been filled prior to submission to Rxmedscanada, and will immediately destroy all copies of the prescription(s), once it has been filled.

13. Acknowledges and understands that once purchased and shipped, no pharmaceutical product may be returned or exchanged.

THE UNDERSIGNED HAS READ AND UNDERSTANDS THESE TERMS AND AGREES THAT THEY SHALL BE BINDING UPON THE UNDERSIGNED AND HIS/HER HEIRS, SUCCESSORS AND PERSONAL REPRESENTATIVES
 

Signature		Witness’s Signature
Print Name Here (please print clearly)		Print Name Here (please print clearly)
Date Signed & Witnessed		City or Town Where Signed & Witnessed