ExpressMedsCanada.com Code: 7500

 Ordering Guide

When form is completed - please fax (along with a copy of the doctor's prescriptions) to:

1.866.793.2987

or mail them to:

PharmaWeb Canada (ExpressMedsCanada.com)
P.O. Box 370
1250 University Street
Montreal, QC H3B 3B0
Canada
 

PLEASE FILL OUT ALL FIELDS COMPLETELY
 

Important! For optimal health and best results of any medication it is important to have had a physical examination in the past 12 months. Have you had one? Y___ N___   (If not, we will require that you schedule an appointment with your physician.)

PATIENT INFORMATION
 
______________________________________________________
Full Name		 ___________
Age
______________________________________________________
Address		 ___________
Date of Birth
_______________________________ ______________________
City                                                          State		 ___________
Sex
______________     ___________________________________
Zip                             Email		 ___________
Height
(        )_______________________    (        )__________________
Phone (Home)                                      Phone (Work)		 ___________
Weight

ALTERNATE SHIPPING ADDRESS
_______________________________________________________
Alternate Shipping Address

_______________________   _________   ________
City   State   Zip
__________________________
Alternate Phone
SHIP TO:

Primary Address:   ___
Alternate Address: ___


PHYSICIAN INFORMATION
__________________________________________
Primary Physician Name		 __________________________________________
Phone
__________________________________________
Name of Clinic / Doctors Office		 __________________________________________
Fax Number
_______________________________________   _______________________   _________   ________
Address   City   State   Zip

Do you require child resistant containers for your medication? Y or N

Please indicate if you would like to receive counseling:   Yes ____     No ____

_____________________________________________________   _______________________
Signature   Date

ExpressMedsCanada.com Code: 7500

Ordering Guide

Have you previously filled out a Medical Questionnaire?    Yes _____    No ____    Not Sure ____

If YES are there any changes Yes (please specify) __________________________________________________ No __________
NOTE: It is only necessary to fill out the Questionnaire once a year, as long as there are no changes. Please indicate if you / your family has a history of any of the following:
Patient Family Medical History
1) Hypertension (high blood pressure) Yes   No
2) Cardiovascular (heart or artery disease) Yes   No
3) Lipid or cholesterol disorder Yes   No
4) Diabetes, thyroid or other endocrine disorder Yes   No
5) Cancer Yes   No
6) Migraine Headaches Yes   No
7) Other Illness Yes   No
 If you answered YES to questions 1 - 7, please explain in more detail, if necessary
 













Patient Medical History
1) High Blood Pressure Yes   No
2) Heart or artery disease including atherosclerosis, angina, palpitation, heart failure or history of heart attack Yes   No
3) Liver Disease Yes   No
4) Renal or Kidney Failure Yes   No
5) Cancer Yes   No
6) Immune Disorders Yes   No
7) Blood Disorders Yes   No
8) Diabetes, thyroid, or other endocrine disorder, including insulin resistance Yes   No
9) Lipid or cholesterol disorder Yes   No
10) Smoker Yes   No
11) Asthma or Emphysema Yes   No
12) Neurological Disorders Yes   No
13) Emotional Disorders Yes   No
14) Poor Wound Healing Yes   No
15) Rheumatoid arthritis, lupus, or connective tissue diseases Yes   No
16) Any known nutrition deficiency including minerals and electrolytes Yes   No
17) Edema (fluid retention) Yes   No
18) Glaucoma Yes   No
19) Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome Yes   No
20) Surgery Yes   No
21) Chemical Dependency Yes   No
19) Other Illness Not Yet Noted Yes   No
*Please indicate any known drug allergies you may have:
____________ ____________ ____________
____________ ____________ ____________
____________ ____________ ____________
If you answered YES to any of the above questions please elaborate in the box below (i.e., duration of illness, any treatment or surgery received, amount smoked and for how long)
 



I hereby confirm that the above information is true and accurate as of the date hereof.

_________________________________________
Patient’s Full Legal Name (Print) 		  ____________________________________________
Patient’s Signature

____________________________________________
Date (Month/Day/Year)

ExpressMedsCanada.com Code: 7500

Ordering Guide

CURRENT MEDICATIONS

Please list all medications you are currently taking and the condition for which they are prescribed.
  Medication & Strength Daily dosage (eg.1 tab daily) Condition
  _______________________________ _______________________ ________________________
  _______________________________ _______________________ ________________________
  _______________________________ _______________________ ________________________
  _______________________________ _______________________ ________________________
  _______________________________ _______________________ ________________________

MEDICATIONS BEING ORDERED TODAY
Medication Strength Quantity Generics Subtotal
_______________________ _____________ ________ Yes No _______________
_______________________ _____________ ________ Yes No _______________
_______________________ _____________ ________ Yes No _______________
_______________________ _____________ ________ Yes No _______________
_______________________ _____________ ________ Yes No _______________
_______________________ _____________ ________ Yes No _______________
(If your order does not fit on the space provided, please attach them on a separate sheet)    Add Shipping           $10.95
Total (US $) $______________

PAYMENT INFORMATION:
VISA  _____ MASTERCARD  _____ AMEX  _____
Card Holder Name (on Card)          ___________________________________________________
Card Holder Address                     ___________________________________________________
Card Holder City __________________ Card Holder Country __________________
Card Holder State __________________ Credit Card Number __________________
Card Holder Zip __________________ Credit Card Expiration __________________  (eg. 11/05)
    * CVV2 # Number __________________
* (required - The CVV2 verification number is a 3-digit (MC & Visa) OR 4-digit (Amex) number printed on the back (MC & Visa) / or front (Amex) of your credit card. It appears on the right hand side of the card.)
Unless otherwise notified in writing, I hereby authorize PharmaWeb Canada to charge my credit card for the cost of all present and future medications ordered plus all associated shipping costs.

____________________________________
Signature 		  ________________________________
Date (Month/Day/Year)

CUSTOMER AGREEMENT - CODE 7500

No prescription(s) will be filled until a signed and dated copy of this document and a completed Patient Profile have been received by PharmaWeb Canada
I, as the undersigned, being over the age of 18, hereby covenant, represent, warrant and confirm to, and acknowledge and agree with, PharmaWeb Canada and its affiliates, related companies, subsidiaries and parent company (hereinafter collectively referred to as "PharmaWeb Canada"), and to the Prescription Processing Centre identified herein (if any), as follows:

Disclosure and Representations

The pharmaceutical(s) to be delivered to me were prescribed by a doctor licensed to practice medicine in the country, state
or other applicable jurisdiction in which I reside or where I sought treatment, and were lawfully obtained from that physician.

Any medication obtained for me by PharmaWeb Canada will be used strictly according to the instructions provided by the physician who prescribed the medication, and only by the person for whom the pharmaceutical(s) were prescribed.

I can make my own medical decisions according to the law of the place where I reside. The prescription(s) I am requesting PharmaWeb Canada to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to PharmaWeb Canada. I agree to immediately destroy all copies of my prescription(s) once it has been filled.

I am not seeking or relying on any medical information from PharmaWeb Canada or the Prescription Processing Centre, and I have
consulted a qualified physician licensed where I obtained the prescription within the last year.

I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me by PharmaWeb Canada.

I understand that it is my responsibility to have regular physical examinations by my primary US licensed physician that is responsible for my care including all suggested testing to ensure that I have no medical problems which would constitute a contradiction to me taking the medications being prescribed.

I acknowledge that PharmaWeb Canada's employees and agents have relied on the information and documentation that I am providing (including the Patient Profile) and I represent and confirm that I have fully disclosed all pertinent information and documentation to PharmaWeb Canada. I agree to notify PharmaWeb Canada of any changes to my physical or medical condition by providing an updated Patient Profile.

Authorization and Consent

I hereby authorize and appoint PharmaWeb Canada, 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 that is the equivalent of the prescription that I sent to PharmaWeb Canada, 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 PharmaWeb Canada employees, agents and service providers including the Canadian physician being retained on my behalf, as required, for the limited purpose of obtaining the Canadian prescription.

I hereby specifically acknowledge that I am aware that PharmaWeb Canada and the Prescription Processing Centre will be transmitting my personal health information by electronic means (for example fax, secure internet) to its employees, agents, affiliates and service providers including the Canadian 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 PharmaWeb Canada and the Prescription Processing Centre, as custodians 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 the transmission by PharmaWeb Canada and the Prescription Processing Centre of my personal health information by electronic means.

If I was directed to PharmaWeb Canada's services through the Prescription Processing Centre, or some other intermediary (for example Pharmacy Benefit Manager, Health Management Organization, or other healthcare service provider), I hereby authorize PharmaWeb Canada to 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 PharmaWeb Canada relating to the protection of my personal health information. I specifically consent to the
transmission of the forgoing information by electronic means.

I authorize and appoint PharmaWeb Canada 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 pharmaceutical(s) and to deliver them to me, to the same extent as I could
do if I were personally present taking those steps and signing those documents myself, and as if I had shipped the
prescribed pharmaceutical(s) to my own address.

I acknowledge and agree that I initiated a consultation with PharmaWeb Canada and that PharmaWeb Canada is not located in the United States. I also acknowledge that the pharmacists working for PharmaWeb Canada and the physicians contracted by PharmaWeb Canada on my behalf are located and licensed to practice medicine or pharmacy in Canada and that all services that I receive from any such Canadian physician and pharmacist are being received in Canada.

I further agree that any and all agreements reached or contracts formed throughout the course of the relationship between me and PharmaWeb Canada shall be deemed to be made in the Province of Quebec, Canada and accordingly shall be governed by the laws of the Province of Quebec and the laws of Canada applicable to such contracts and agreements.

I agree that any dispute that arises between me and PharmaWeb Canada, its officers, directors, employees, agents and contractors shall be governed by the laws of the Province of Quebec and the laws of Canada applicable to contracts formed in Quebec, and I agree that the courts of the Province of Quebec shall have sole and exclusive jurisdiction over any such dispute.

Purchase and Sale Terms

PharmaWeb Canada will charge my credit card the following amounts:

The medication price and shipping (in US dollars) as posted on the PharmaWeb Canada web site on the day PharmaWeb Canada receives my order; and in
the event my payment is not authorized, PharmaWeb Canada has the right to cancel my order and attempt to provide me with notice of
such cancellation.

The pharmaceutical(s) will not be packaged in child protected packaging, unless requested by me on the Patient Questionnaire.

PharmaWeb Canada shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available in accordance with the Manitoba Drug Standards and Therapeutic Formulary, unless the physician has indicated that there be "no substitution". That once purchased and shipped, no pharmaceutical product may be returned or exchanged.

PharmaWeb Canada reserves 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.

PharmaWeb Canada does not provide its agency or attorney services as a substitute for healthcare or the advice of the customer's primary care physician.

PharmaWeb Canada will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me
by the supplying pharmacy does not correspond with my prescription.

The Prescription Processing Centre is acting as my agent in completing the forms and taking such other actions as are necessary to request PharmaWeb Canada to send me the prescriptions I am requesting, and is not the agent, express or implied, of PharmaWeb Canada. In this regard, but without limiting the generality of the foregoing, I acknowledge and agree that the Prescription Processing Centre does not have the authority to assume or create any obligation whatsoever, expressed or implied, in the name
of PharmaWeb Canada, or to otherwise bind PharmaWeb Canada in any manner whatsoever.

I have read and understood the terms and conditions set out in this Agreement and agree, on behalf of myself, my heirs, successors, administrators and assigns to be bound by these terms and conditions. 

Signed this _______________ day of _______________, 2004.

________________________________________________   _______________________________________
(Signature)   (Print Name) (Please Print Clearly)

Please check everything over carefully and remember to SIGN and DATE every page that you send to us.