This Patient Acknowledgement must be signed and delivered to PharmacyRxWorld.com, which carries on business as PharmacyRxWorld.com (hereinafter "PharmacyRxWorld.com")(which includes its agents, affiliates, representatives, agents, contractors and sub-contractors) by every patient or customer ("I" or "me").
I acknowledge and agree as follows:
1. Regarding orders for a prescription drug:
A) I must have already been taking the prescribed medication for a minimum period of 30 days immediately prior to the date that I submit my prescription to PharmacyRxWorld.com for filing;
B) I hereby authorize and appoint PharmacyRxWorld.com 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 in Canada or elsewhere that is the equivalent of the prescription that I will send to PharmacyRxWorld.com to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization includes but is not limited to: collecting personal health information about me; collecting similar information from my prescribing physician ("My Own Physician") or pharmacist, disclosing that information to PharmacyRxWorld.com and having a Canadian physician ("Canadian Physician") perform an independent medical review of my medical information.
2. There are no additional fees charged to me in connection with the Canadian Physician reviewing my medical information.
3. 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 for me by My Own Physician. I agree that should I suffer any adverse affects while taking any prescription medication that I w ill 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 acknowledge and agree that PharmacyRxWorld.com recommends regular physician examinations with My Own Physician whose care I am under and who initially prescribed my medications.
4. I understand and agree that treatment, if any, other than treatment that may be received by using any product purchased through PharmacyRxWorld.com, shall be deemed to be received by me in Canada. I understand and agree that treatment, if any, received by using any product purchased through PharmacyRxWorld.com, shall be deemed to be received by me in the jurisdiction from which the product was shipped.
5. I further understand that PharmacyRxWorld.com will only verify and provide mediations that My Own Physician has already prescribed to me. No new prescription medications will be provided by PharmacyRxWorld.com. I also understand that no controlled medications, narcotics, tranquilizers, or other medications that PharmacyRxWorld.com decides are inappropriate, will be provided.
6. I hereby waive any requirement of the Canadian Physician to conduct a physical examination.
7. I understand and agree that the review of my medical information by a Canadian 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. I understand that any opinions, advice, statements, services, offers or other information expressed or made available by third parties (including merchants and licensors) are those of the respective authors or distributors of such content.
8. I understand that medications dispensed from PharmacyRxWorld.com's Canadian pharmacy must be dispensed in child-resistant packaging unless I indicate on the Order Form that I do not wish to have my medications dispensed in that manner. For medications dispensed by PharmacyRxWorld.com's affiliated dispensaries outside of Canada, I direct that dispensary to dispense any medications ordered by me in the manufacturer's original packaging wherever it is both possible and reasonable to do so under the circumstances. In the event that I wish my medications to be dispensed in child-resistant packaging instead of the manufacturer's original packaging, I will advise PharmacyRxWorld.com of this preference at the time I make my order.
9. I hereby confirm that I am eighteen years of age or older and I am fully competent to make my own health care decisions. I am aware of the potential side effects and/or problems associated with prescription medications and understand that it would be a violation of law to falsify any information on my medical questionnaire or other medical records for the purposes of obtaining prescription medication. I agree to truthfully, and to the best of my knowledge, to answer all of the questions on my medical questionnaire. I agree that if I fail in any way to fully furnish my complete and accurate medical history or I become aware of any changes in my physical or medical condition in the future and I fail to notify PharmacyRxWorld.com of such failure, I am solely responsible for any adverse effects that I may suffer from taking or continuing to take such prescribed medications.
10. I certify that I have had a physical examination by My Own Physician within the last 2 months from the date hereof.
11. I authorize and appoint PharmacyRxWorld.com as my agent and attorney for the purpose of taking all steps and signing all documents on my behalf necessary to package or re-package the products I will order in order to have them delivered to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.
12. I authorize and appoint PharmacyRxWorld.com as my agent and my attorney for the purpose of taking all steps and signing all documents on my behalf necessary for shipping the products I will order as if I had shipped them to my own address.
13. I initiated contact with PharmacyRxWorld.com and understand that PharmacyRxWorld.com is not located in the United States.
14. The contract for sale for any product I purchase from PharmacyRxWorld.com occurs in and is completed in the jurisdiction from which such product purchase is shipped from. Title to any product ordered by me passes from PharmacyRxWorld.com to me at the time the product leaves PharmacyRxWorld.com's affiliated dispensary.
15. All disputes between me and PharmacyRxWorld.com arising out of or in connection with my dealings with PharmacyRxWorld.com shall be governed by the laws of the Province of Ontario and the laws of Canada applicable therein, without regard to conflict or laws principles. All disputes, controversies or claims arising out of or in connection with my dealings with PharmacyRxWorld.com shall be submitted to and subject to the jurisdiction of the courts of the Province of Ontario, Canada. PharmacyRxWorld.com and I submit to the exclusive jurisdiction of the courts of the Province of Ontario to finally adjudicate or determine any suit, action or proceeding arising out of or in connection with my dealings with PharmacyRxWorld.com.
16. I understand that I am ordering
from an international pharmacy and that once the pharmacy ships my medications,
ALL SALES ARE FINAL. We are unable to take returns. I understand that
prices are SUBJECT TO CHANGE without prior notice. When placing an order,
please call to receive current pricing.
I HAVE READ AND UNDERSTAND THE ABOVE REFERENCE PATIENT ACKNOWLEDGEMENT AND AGREE TO EACH OF THE FOREGOING TERMS. |
