Prescription Drug Purchase Agreement by izu13039

VIEWS: 19 PAGES: 4

More Info
									                                                                                                                                                  TOTAL DRUG CARE                     1 of 4




purchase agreement
Manitoba Pharmacy #32241 CUSTOMER PURCHASE AGREEMENT                                        When Medication is Being Dispensed to an Individual Not in the
                                                                                            Store, Including Residents of Other Provinces or Countries
In consideration of Manitoba Pharmacy #32241 filling my prescription, and for other         1. I name and authorize Manitoba Pharmacy #32241, as my agent and attorney for
good and valuable consideration, the receipt and sufficiency of which is hereby             the limited purposes of taking all steps and signing all related documents on behalf
acknowledged by me, I hereby agree as follows:                                              of myself necessary to appoint the third party such as a courier or postal service that
                                                                                            will act as my agent for the purposes of picking up, then delivering to my address,
Regarding my Medication(s)                                                                  the medication(s) I have ordered. Manitoba Pharmacy #32241 has the same
1. I will be the only person using my medication(s) and I will use them as prescribed.      authority in this regard as I would if I was personally present, taking those steps
2. I am not ordering more than a 3 month supply of my medication(s).                        myself, including signing any documents connected with shipment of the
3. I understand that my medication(s) cannot be returned for exchange or refund.            medication(s) to my address.
4. I understand that Manitoba Pharmacy #32241 may substitute a generic drug for a           2. I acknowledge and understand that Manitoba Pharmacy #32241 will release my
brand name prescription drug, where available, in accordance with the Manitoba              medication(s) under my authority to the third party appointed by Manitoba Pharmacy
Drug Standards and Therapeutic Formulary, unless the physician has indicated there          #32241, as my agent, pursuant to the power of attorney I have granted to them in
be no such substitution.                                                                    paragraph 1 above, to pick up, then deliver, my medication(s) to me. I acknowledge
5. The medication(s) I am ordering were prescribed by a physician licensed to               that such third party is acting as an agent on my behalf, and as such I am importing
practise medicine in the country, province, territory, state, or other applicable           the medication(s) into the country, province, territory or other applicable jurisdiction
jurisdiction, in which I reside.                                                            in which I reside, and own such medication(s) when Manitoba Pharmacy #32241
6. The prescriptions for the medication(s) to be delivered to me were lawfully              provides such medication(s) to my agent.
obtained from my physician.                                                                 3. I acknowledge that the Canadian cosigning physician evaluates my medical profile
7. I authorize Manitoba Pharmacy #32241 to take any and all steps necessary to              and may approve my prescription but is in no position to modify my medication(s).
complete the sale of the medication(s) to me in the Province of Manitoba, Canada.           This relationship does not replace that of my primary physician.
8. I acknowledge and understand that the sale to me takes place in the                      4. I hereby confirm that prior to ordering a particular medication from Manitoba
Province of Manitoba, Canada, and that I become the owner of the                            Pharmacy #32241 for the first time, I will have taken such medication for at least
medication(s) when Manitoba Pharmacy #32241 places the medication(s) in a                   thirty (30) days prior to providing Manitoba Pharmacy #32241 with my prescription or
container or otherwise completes the steps necessary to prepare it for my use.              order in respect of each such particular medication or other product, as the case
Manitoba Pharmacy #32241 will then transfer possession of the medication(s)                 may be
to me, or to my agent who is appointed on my behalf by Manitoba Pharmacy
#32241, which may include a post office or a courier. I am the person who is                Release & Disputes:
responsible for transporting the medication(s) to my address, whether it is in              1. I attorn to the jurisdiction of Manitoba and agree that any dispute that arises
Manitoba or in another Province or another country. Any steps connected with                between myself and Manitoba Pharmacy #32241, its affiliates, related companies,
transportation are carried out by me or by someone acting as agent on my                    subsidiaries, officers, directors, shareholders, employees or agents shall be
behalf.                                                                                     governed by the laws of the Province of Manitoba and the laws of Canada applicable
                                                                                            to contracts formed in Manitoba, and I agree that the courts of the Province of
My Information                                                                              Manitoba shall have sole and exclusive jurisdiction over any such dispute, including,
1. I am of the age of majority and I am not restricted from making my own medical           but not limited to any claims of negligence and/or malpractice. Further, I agree that
decisions.                                                                                  any and all agreements reached, or contracts formed, throughout the course of my
2. By obtaining that/those prescription(s) for my ordered medication(s), I have not         relationship with Manitoba Pharmacy #32241 shall be deemed to be made in
broken laws of the country, province, territory, state, or other applicable jurisdiction,   Manitoba, and accordingly shall be governed by the laws of Manitoba, and the laws
in which I reside.                                                                          of Canada applicable to such contracts and agreements, and I acknowledge that I
3. It is my responsibility to have regular physical examinations by my licensed             am benefiting from such laws by purchasing medication(s) from Manitoba Pharmacy
primary physician, including all suggested tests to ensure I have no medical                #32241
problems that contraindicate my taking the medication(s).                                   2. I release and discharge Manitoba Pharmacy #32241 and its officers, directors,
4. I understand that the collection, retention, disclosure and use of my personal           shareholders, agents and employees from any and all liability, claims or causes of
health information by Manitoba Pharmacy #32241 shall be governed by the privacy             actions due to any act, error or omission on the part of any third party who is my
policy of Manitoba Pharmacy #32241 in effect, and as amended, from time to time.            agent for the purposes of transporting the medication(s) to my address, including
                                                                                            any agent who is appointed on my behalf by CanAmerica.
Dispensing of Medication(s)                                                                 3. Manitoba Pharmacy #32241 hereby warrants:
1. I acknowledge that Manitoba Pharmacy #32241 and agents rely on the health                     (a) with respect to service, that it will exercise reasonable care in filling a
information and documentation that is provided by me. This includes my patient                   prescription in accordance with the prescription received, and the accompanying
questionnaire and all other related information I forward to Manitoba Pharmacy                   documentation and information;
#32241 I represent and confirm that I have, to the best of my knowledge, fully                   (b) with respect to the quality of its products, that it will honor all the warranties
disclosed all pertinent information and documentation for my prescriptions. I agree              contained in s.58 of The Consumer Protection Act (Manitoba).
that I will notify Manitoba Pharmacy #32241 of any changes to my physical or                I understand that Manitoba Pharmacy #32241 makes no warranties beyond these,
medical condition by providing an updated patient questionnaire.                            and I release Manitoba Pharmacy #32241 and its officers, directors, shareholders,
2. I understand that when possible, my medication(s) will be in original                    agents and employees from any or all liability, claims or causes of action, to the
manufacturer’s packaging which may or may not be in child resistant packaging, and          extent that loss or damage is not caused by a breach of these warranties. In
I must indicate if I choose or choose not to have child resistant packaging.                particular, I understand that Manitoba Pharmacy #32241 is not responsible for errors
3. I understand that, in all cases, Manitoba Pharmacy #32241 must receive a valid           made by prescribing physicians, for problems that arise from my failure or that of my
prescription for fulfillment, which prescription must be written by, or in the case of      agent to provide full and accurate information in accordance with this Customer
those prescriptions which are written by a physician licensed in a jurisdiction other       Purchase Agreement, from side-effects of the medication(s) or from the failure of the
than a province or territory of Canada, co-signed by, a physician licensed in Canada.       medication(s), in my case, to produce a particular effect that I or my physician expect
4. I understand that habit forming, narcotic, or any other controlled medication(s)         or desire.
require the customer themselves, to personally pick up the medication(s) as they are
not permitted to be delivered and will only be dispensed at the Manitoba Pharmacy           By agreeing to this document I confirm that I have read and
#32241 pharmacy in accordance with the guidelines of the Manitoba Pharmaceutical            understood these terms and that they are true and correct and I
Association.                                                                                agree that the terms herein are binding on me and my heirs assigns,
5. I acknowledge Manitoba Pharmacy #32241 to be a pharmacy located in the                   successors and personal representatives.
Province of Manitoba, Canada, licensed by the Manitoba Pharmaceutical
Association, licence #32241, and agree that I have initiated the consultation. I also
acknowledge that the CanAmerica Drugs pharmacists and contracted physicians are
located and licensed to practise pharmacy or medicine, as the case may be, in
Canada, and that all treatment I am receiving from the said pharmacists and
physicians is being received in Canada.




Signature                                                                                       Date

Customer Name (print)
                                                                                                                                                                  Version 08062004
                                                                                                     TOTAL DRUG CARE     2 of 4




customer details
 Billing Information

Date (mm-dd-yyyy)
First Name
Last Name
Address
City                                                              State/Province
Country                                                           Zip/Postal Code
Telephone (Home) (                   )                            Telephone (Day) (      )
Fax (            )                                                Email


   Same as Billing Information

 Shipping Information (if different from above)

First Name
Last Name
Address
City                                                              State/Province
Country                                                           Zip/Postal Code


 General Information

Height (Feet/Inch)               '       "                        Weight           lbs
Birth Date (mm-dd-yyyy)                                           Sex:          male     female

Drug Packaging:                  Please supply me with child resistant containers/packaging
                                 No, do not supply me with child resistant containers/packaging


 Payment

Payment Type:                    Quote Only         Credit Card           Bank Draft         International Money Order
Credit Card Type:                MasterCard         Visa
Credit Card Number                                                                           Expiry Date       /
Card holder’s Name (as it appears on card)
Card holder’s Signature

Please enter all information below exactly as it appears on your credit card statement:
Telephone (               )
Address
City                                                              State/Province
Country                                                           Zip/Postal Code
                                                                                                                                    TOTAL DRUG CARE                   3 of 4




medical history
Please answer ALL the questions below, if answer 'Yes' please circle applicable condition and give details:
1a.     HEART & BLOOD, e.g. High Blood Pressure, High Cholesterol, Coronary Artery Disease, Heart Attack, Murmur, Congestive Heart Failure, Angina,
        Swelling of Ankles, Irregular or Rapid Pulse, Hemophilia, Leukemia, Sickle Cell Anemia, Blood Clotting etc.?

            yes           no                if “YES”, please provide details:


1b.     NOSE, THROAT & LUNGS, e.g. Asthma, Bronchitis, Persistent Cough, COPD, Pleurisy, Emphysema,etc.?

            yes           no                if “YES”, please provide details:


1c.     LIVER, STOMACH, INTESTINES, KIDNEYS, BLADDER & GENITAL ORGANS, e.g. Hepatitis, Ulcers, Acid reflux, Frequent Indigestion, Ulcerative
        Colitis, Crohns Disease, Inflammation, kidney dialysis, enlarged prostate, Stones, Pus or trouble urinating, sexually transmitted diseases etc.?

            yes           no                if “YES”, please provide details:


1d.     NERVOUS SYSTEM & PSYCHIATRIC CONDITIONS, e.g., Neurological Disorders, Epilepsy, Seizure, Parkinsons, Migraines, Convulsions, Stroke,
        Alzheimer’s disease, Glaucoma, Cataracts, Nervous Breakdown, Anxiety, Depression, Bipolar, Schizophrenia etc.?

            yes           no                if “YES”, please provide details:


1e.     GLANDULAR SYSTEM, e.g. Thyroid, Endocrine disorder, Anemia, Diabetes, Gout, Enlarged Lymph Nodes, etc.?

            yes           no                if “YES”, please provide details:


1f.     SKIN, MUSCLES, BONES & JOINTS, e.g. Arthritis, Osteoporosis, Frequent Fractures, Paralysis, Unusual Skin Lesions, Psoriasis, Eczema, etc.?

            yes           no                if “YES”, please provide details:


1g.     IMMUNE SYSTEM, e.g. Immune Deficiencies, Tested Positive to Aids/HIV, etc.?

            yes           no                if “YES”, please provide details:


2.      Have you undergone Diagnostic tests or Surgery within the last 12 months or been treated for a Tumor or Cancer?

            yes           no                if “YES”, please provide details:


3.      Do you have severe Allergies?

            yes           no                if “YES”, please provide details:


4.      Do you currently take Neutraceuticals, e.g. Vitamins, Minerals, Herbs, etc.?

            yes           no                if “YES”, please provide details:


5.      Do you exercise regularly?

            yes           no                if “YES”, please provide details:


6.      Is there any significant family (mother, father, brother, sister) history of illness, e.g. Huntingtons Chorea, Diabetes, Seizure Disorders, Heart or Kidney
        Disease, etc.?

            yes           no                if “YES”, please provide details:


7.      Is there any other medical condition or history not mentioned above the Physician should be aware of?

            yes           no                if “YES”, please provide details:


8.      Are there any other medications you are currently taking? If so please list ALL these medications.

            yes           no                if “YES”, please provide details:
                                                                                             TOTAL DRUG CARE.             4 of 4




physician info
Occasionally, we are required to contact your physician to verify particulars of your prescriptions. Please
fill out the following form with your current physician information for our records.


Primary Physician Name
Address
City                                                         State/Province
Country                                                      Zip/Postal Code
Telephone (              )                                   Fax (       )

License Number
Date Last Consulted (mm-dd-yyyy)
Reason




 Canadian only: please fill out the following Information.

Provincial Health Care Number
Secondary Insurance Plan Number
Type of Plan
Other (Please specify)


 Prescription Details

Please enter details of the medications you are ordering
  Drug Name                                                  Strength          Quantity         Price (US)




                                                                               Shipping           $15.00
                                                                                   Total




                                                                                                       Version 08062004

								
To top