Client Agreement & Authorization Form
This Client Agreement and Power of Attorney, also known as Client Agreement and Authorization, (this “Agreement”), consisting of two (2) pages, must be signed, dated and delivered to CanadianPharmacyMeds.com (“ CPM”), a provider of international pharmacy referral and administration services, by any customer or client (“I” or “me”) who is purchasing prescription medications (“Medications”) through CPM by using the CPM prescription service. I acknowledge and agree with CPM as follows:
- 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.
In the case of paragraph 1 above, if I do not agree with all of the following terms and conditions, I agree that I will not place any orders. In the case of paragraph 2 above, if I do not have that person’s consent, permission or authorization or that person does not agree with all of the terms below, I agree that I will not place any orders.
- I understand, acknowledge, and agree that all prescriptions are being provided by a CPM affiliated Canadian pharmacy and/or International fulfillment center and that the information and services provided by CPM are strictly for the purposes of assisting me in filling a prescription prescribed by a qualified physician licensed where I obtained the prescription. Furthermore, I understand, acknowledge, and agree that the medications I order through CPM may be filled and shipped by an approved fulfillment center located in a country outside of Canada (each referred to as an "International Fulfillment Center") and that these countries can include, but are not limited to, Australia, United Kingdom, New Zealand, Turkey, Singapore, Mauritius, and the United States. I understand, acknowledge, and agree that the products I order are sourced from various countries including, but not limited to, Canada, United Kingdom, New Zealand, Turkey, India, Australia, and the United States. I understand, acknowledge, and agree that title to any product(s) ordered by me passes from the pharmacy or fulfillment center that fills my order to me when the products(s) are shipped.
- I acknowledge that CPM is required to have a licensed Canadian and/or International Physician (the “Canada MD” and “International MD” respectively) review my medical information and that CPM and its delegates, employees and contractors have relied on the information and documentation provided by me and I represent that I have fully disclosed all pertinent requested information and documentation to CPM. I understand and acknowledge that the International MD is a medical physician fully licensed in a country outside of Canada. I hereby waive any requirement to have the Canadian and/or International MD conduct a physical examination of me. I acknowledge that there are no fees charged to me arising from the Canadian and/or International MD reviewing my medical information. If there is any change to my physical or medical condition or any change in medications I am taking, I shall notify CPM of such changes by providing an updated patient profile and medical history questionnaire at the time I am ordering additional medications. I certify that I have had a physical examination by a doctor licensed to practice medicine in the country, state, or other applicable jurisdiction in which I reside (“My Own Physician”) within the last 12 months from the date hereof. I will also agree to a medical follow up with my physician after receiving my medications.
- I hereby give permission to My Own Physician to release any and all medical information and data whatsoever which CPM, the Canadian and/or International Physician or Pharmacist shall request for the purpose of performing a medical review to determine whether the Medications prescribed by My Own Physician are appropriate in the circumstances. I understand that this will include reviewing the medical questionnaire and information submitted by My Own Physician and that CPM, the Canadian and/or International Physician or Pharmacist may contact My Own Physician for more information.
- I understand that it is my responsibility to have My Own Physician conduct regular physical examinations of me, including any and all suggested testing by My Own Physician to ensure that I have no medical problems which would constitute a contraindication to me taking medications prescribed by My Own Physician. I agree that should I suffer any adverse affects while taking any prescription medication that I will immediately contact My Own Physician and that in the event 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 AGREE THAT THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN SHALL NOT BE LIABLE FOR ANY LIABILITY, CLAIM, LOSS, DAMAGE OR EXPENSE OF ANY KIND OR NATURE CAUSED DIRECTLY OR INDIRECTLY BY ANY INADEQUACY, DEFICIENCY OR UNSUITABILITY OF ANY PRESCRIPTION ISSUED BY THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN OR THE INADEQUACY, DEFICIENCY OR UNSUITABILITY OF THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN’S REVIEW OF MY MEDICAL INFORMATION. IN NO EVENT WILL THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN BE LIABLE OR RESPONSIBLE FOR ANY DAMAGES WHATSOEVER, INCLUDING, DIRECT, INDIRECT, PUNITIVE, SPECIAL OR CONSEQUENTIAL DAMAGES, EVEN IF ADVISED OF THE POSSIBILITY THEREOF.
- I understand and acknowledge that CPM is not a pharmacy and does not provide any medical advice. I further understand and acknowledge that CPM is an international pharmacy referral and administration service established to help me obtain my medications from an approved pharmacy or fulfillment center.
Authorization, Consent and Power of Attorney
* I hereby authorize and appoint CanadianPharmacyMeds.comand its agents, affiliates, employees and contractors as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to obtain a prescription from a licensed Medical Doctor in Canada or other country that is the equivalent of the prescription included in this order, to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization shall include, but not be limited to: collecting personal health information about me; collecting similar information from my prescribing physician or pharmacist, and disclosing that personal health information to CPM employees, agents, affiliates, contractors, and service providers including the Canadian and/or International Physician being retained on my behalf, as required, for the limited purpose of obtaining the Canadian and/or International prescription, and purchasing and arranging delivery of the medications prescribed in the Canadian and/or International prescription.
* I hereby consent to CPM, the Canada and International MD, and any approved Canadian pharmacy and International Fulfillment Center 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, medical information, payment and other information and verifying future orders.
* I hereby acknowledge and understand that CPM will in all instances substitute generic drug equivalents unless specified otherwise by My Own Physician or myself. I also understand that CPMwill in all instances use Canadian or International drug equivalents, including generics, to fill my order, and therefore brand names may vary. I understand and acknowledge that International drug equivalents refer to drug equivalents from countries outside of Canada.
* I hereby specifically acknowledge that I am aware that CPMwill be transmitting my personal health information by electronic means (for example fax, secure internet) to its employees, agents, contractors, affiliates and service providers including the Canadian and/or International Physician retained on my behalf. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that CPM, as a custodian of my personal health information will take all appropriate precautions to protect my personal health information from improper disclosure or use. I hereby consent to CPM's transmission of my personal health information by electronic means.
* If I was directed to CPM's services through an affiliate or intermediary (for example Pharmacy Benefit Manager, Health Management Organization, or other healthcare service provider), I hereby authorize CPMto release the following data to such an intermediary:
- a numerical identifier indicating that I was a patient referred from that source;
- financial information that will permit the processing of any claims on my behalf;
It is my understanding that all such intermediaries will enter into Confidentiality Agreements where they agree to abide by the privacy policies of CPM relating to the protection of my personal health information. I specifically consent to the transmission of the forgoing information by electronic means.
Disclosure And Representations
* I represent that ALL of the following statements are true and agree that CPMand its employees and 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 country, state, or other applicable jurisdiction where I reside;
- The prescription I am requesting CPM to assist me in obtaining was prescribed by a qualified physician licensed where I obtained the prescription;
- The prescription I am requesting CPM to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to CPM. I agree to immediately destroy all copies of my prescription once it has been filled;
- The prescription I am requesting CPM to assist me in obtaining is not more than one year old from the date the prescription was originally written;
- With respect to any of the medications which I now or hereinafter order from CPM, I will take the same for at least 30 days immediately prior to the date that I submit my order to CPM;
- I am not violating any laws where I reside by placing this order;
- I will use any medication obtained for me by CPM 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 CPM 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 or my primary physician in the event I suffer any unexpected side effects from any medication obtained for me by CPM.
- I understand, acknowledge, and agree that by placing my order (or initiating my order) through the CanadianPharmacyMeds.com website, I become a customer of CanadianPharmacyMeds.com and therefore may receive communications from CanadianPharmacyMeds.com concerning my order or other promotional offers.
* CanadianPharmacyMeds.comhas 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
* CPM, through its contracted billing services provider Global Health Supplies, will charge my credit card the following amounts for each order: the TOTAL COST OF THE MEDICATIONS as posted on the CPM Website or CPM internal pricing system on the day CPM receives my order and SHIPPING AND HANDLING COST for each package CPM ships.* CPM, through its contracted billing services provider Global Health Supplies, will charge my credit card a $30 fee for each cancelled order.
* In the event my payment is not authorized, CPM has the right to cancel my order and attempt to provide me with notice of such cancellation.
* CPMreserves 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.
* CPMdoes not provide its agent or attorney services as a substitute for health care or the advice of a physician.
* CPMwill not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the supplying pharmacy or fulfillment center does not correspond with my prescription.
Release And Waiver
* I hereby release and save CPMand its employees, officers, directors, delegates, agents, affiliates 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 CPM including, without limitation, any and all side effects whether previously known or unknown;
- CPM 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 CPM affiliated pharmacy or fulfillment center or pharmacist contractors from compliance with the applicable standards of practice or usual professional duties and obligations, which a pharmacist owes.
* If any term or provision of this agreement is determined to be invalid or unenforceable by any court, such determination shall not invalidate the rest of this agreement which shall remain in full force and effect as if the invalid term or provision had not been made part of this agreement.
* I specifically acknowledge and agree that any dispute that arises between me and CPM or any of the CPM agents shall:
a. insofar as such dispute relates to CPM or any of CPM's agents located in Canada, be governed by the laws of the Province of British Columbia and the law of Canada applicable to contracts formed in British Columbia, and that the Courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such disputes; and
b. insofar as such dispute relates to any CPM agents located elsewhere in the world, the disputes should be governed by the local laws applicable to the contracts formed in that jurisdiction and the courts of that jurisdiction shall have sole and exclusive authority over any such dispute.
I, the client, have read, understood and agree to all of the foregoing in this two (2) page document entitled ‘Client Agreement & Power of Attorney’.