|
Reordering Prescription Drugs
--------------------------------------------------------------------------------
For legal purposes the "UPDATED RxMedscanada Patient Release Form
" must be agreed to before
a refill request is made. Once you have clicked on "I
Agree" you will be taken to the refill request page.
--------------------------------------------------------------------------------
RxMedscanada Patient Release Form
By Clicking I agree, it serves as your signed agreement to
this Limited Power of Attorney & Release Form.
THE UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY:
1. Represents and confirms to 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 my responsibility to have regular
physical examinations by the U.S. licensed physician whose
care I am under, including all suggested testing by said physician
to ensure I have no medical problems which would constitute
a contradiction to me taking the medications being prescribed
for me.
4. Authorizes and appoints RxMedscanada, as his/her agent and
his/her attorney for the limited purpose 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 package or repackage
the pharmaceutical(s) and to deliver them to the undersigned,
to the same extent as if the undersigned could do if he/she
were personally present taking those steps and signing those
documents himself/herself.
5. 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 has shipped the prescribed pharmaceutical(s)
to himself/herself to the undersigned's address.
6. Understands and acknowledges that the pharmaceutical(s)
will not be packaged in child protective packaging 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.
7. 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 physicians and pharmacists working for RxMedscanada
are located and licensed to practice medicine or pharmacy
in Canada and that all treatment I am receiving from the said
physician and pharmacist is being received in Canada.
8. 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.
9. 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.
10. Understands that RxMedscanada shall be entitled to substitute
a prescription drug with a generic drug where available unless
the physician has indicated that there be "no substitution".
11. Acknowledges and understands that once purchased and
shipped, no pharmaceutical product may be returned or exchanged.
|
