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AGREEMENT FOR SERVICES
A. DISCLOSURE AND REPRESENTATIONS BY CUSTOMER:
I, the undersigned, acknowledge, represent and confirm to
PurelyCanadianDrugs and to Coastal Canada Pharmacy.
(hereinafter collectively referred to as " PurelyCanadianDrugs ") that:
The prescription(s) that I submit to PurelyCanadianDrugs for the
medications (referred to in this Agreement as "pharmaceuticals" or
"medications") described in the prescription were prescribed by a physician
("My Doctor") licensed to practice medicine in the country, state or other
applicable jurisdiction in which I reside or where I sought treatment and who I
personally consulted.
The prescription(s) were lawfully obtained by me from My Doctor.
I will continue to have my medical condition and my use of the
pharmaceuticals obtained through PurelyCanadianDrugs monitored by My Doctor on a
regular basis as My Doctor may advise me.
I am engaging PurelyCanadianDrugs for the sole purpose of obtaining
prescription medications at a lower price than in the country in which I
reside.
I am not seeking medical advice or medical treatment of any kind or
nature whatsoever from PurelyCanadianDrugs nor am I relying upon any medical
information from PurelyCanadianDrugs or from any of its employees, officers, agents or
any and all others acting through or for PurelyCanadianDrugs.
I understand that neither PurelyCanadianDrugs nor any of its employees,
officers agents and all others acting through or for it, nor anyone that is
acting on its behalf, is providing medical advice, treatment advice or
treatment of any kind whatsoever to me.
I will use any pharmaceuticals obtained for me by PurelyCanadianDrugs
strictly according to the instructions provided by My Doctor.
The pharmaceuticals will only be used as directed and only by me.
I can make my own medical decisions according to the law of the
place where I reside.
The prescription(s) for the pharmaceuticals has not been altered in
any way nor has it been filled prior to submission to PurelyCanadianDrugs.
I will immediately contact My Doctor in the event that I suffer any
side effects from any pharmaceuticals.
It is my responsibility to have regular physical examinations by My
Doctor including all testing to ensure that I have no medical problems which
would constitute a contradiction to me taking the pharmaceuticals.
PurelyCanadianDrugs's employees and agents have relied on the information
and documentation that I have provided or will provide (including the Patient
Profile) and I represent and confirm that I have fully disclosed all pertinent
and relevant information and documentation to PurelyCanadianDrugs. I agree to promptly
notify PurelyCanadianDrugs of any changes to my physical or medical condition by
providing an updated Patient Profile.
I understand that:
Coastal Canada Pharmacy is duly licensed in the Province of
British Columbia, Canada and is located at 1006 - 7495 - 132nd Street, Surrey,
British Columbia, Canada (Phone: 604-598-4673; Fax: 604-598-8795). Coastal Canada pharmacy manager is Grace Lee. PurelyCanadianDrugs is located at Suite #196, 7231 - 120th Street,
Delta, B.C.,
Canada V4C 6P5 (Toll Free Phone: 1-866-643-2762 ; Toll free fax: 1-866-732-0306).
PurelyCanadianDrugs Healthcare Solutions Inc's manager is Wendy Morris.
B. AUTHORIZATION AND CONSENT
I hereby authorize and appoint PurelyCanadianDrugs, 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(s) in Canada that is the
equivalent of the prescription(s) for the pharmaceuticals that I have forwarded
to PurelyCanadianDrugs, 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 PurelyCanadianDrugs 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. The authorizations and consents that I am providing to
PurelyCanadianDrugs commence on the date I have signed this agreement and shall
continue until I revoke them. I understand that I can revoke the consents and
authorizations I have granted to PurelyCanadianDrugs at any time.
I hereby specifically acknowledge that I am aware that PurelyCanadianDrugs
will be transmitting my personal health information by electronic means (for
example fax, secure internet) to its affiliates and service providers including
the Canadian physician retained by PurelyCanadianDrugs on my behalf to obtain the
Canadian prescription(s). I understand that the use of electronic means will
enhance the efficiency and timeliness of processing my order. I also understand
that PurelyCanadianDrugs, 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 PurelyCanadianDrugs's transmission of
my personal health information by electronic means.
If I was directed to PurelyCanadianDrugs's services through an affiliate,
intermediary or other healthcare service provider Herein called an
"intermediary") I hereby authorize PurelyCanadianDrugs to release the following data to
such intermediary: a numerical identifier indicating that I was a patient
referred from that intermediary; 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 will agree to abide by the privacy
policies of PurelyCanadianDrugs 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 PurelyCanadianDrugs 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.
I authorize and appoint PurelyCanadianDrugs as my agent and my attorney for
the purpose of taking all steps and signing all documents on my behalf
necessary for shipping my prescribed pharmaceuticals to me as if I had shipped
them myself to my own address.
I understand that PurelyCanadianDrugs is located in Canada, not in the
United States. I also acknowledge that the pharmacists working for PurelyCanadianDrugs
and the physicians contracted by PurelyCanadianDrugs on my behalf are located and
licensed to practice medicine or pharmacy in Canada and that all services that
I receive from the Canadian pharmacy and the 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 PurelyCanadianDrugs
shall be deemed to be made in the Province of British Columbia, Canada and
accordingly shall be governed by the laws of the Province of British Columbia,
Canada and the laws of the Country of Canada.
I agree that any dispute that arises between me and PurelyCanadianDrugs,
its affiliates, related companies, subsidiaries, parent company, officers,
directors, employees, agents and contractors shall be governed by the laws of
the Province of British Columbia and I agree that the courts of the Province of
British Columbia shall have sole and exclusive jurisdiction over any such
dispute.
If a problem arises, I understand that I may need to contact the
College of Pharmacists for the Province of British Columbia located at 200 -
1765 West 8 th Avenue, Vancouver, British Columbia, Canada (Phone 604-733-2440
or 1-800-663-1940; Fax: 604-733-2440 or 1-800-377-8129) to report my concern.
C. PURCHASE AND SALE TERMS
I hereby acknowledge, understand, authorize and agree that:
PurelyCanadianDrugs may charge my credit card account for the pharmaceutical(s)
price(s) plus shipping (in US Dollars) as is posted on the PurelyCanadianDrugs web site
on the date that PurelyCanadianDrugs completes my order.
In the event my payment is not authorized, I understand that
PurelyCanadianDrugs has the right to cancel my order. In such event PurelyCanadianDrugs will
attempt to provide me with notice of such cancellation. After an order has been
sent to the pharmacy I may not cancel the order and the sale is final. The
pharmaceutical(s) will be packaged in child protected packaging, unless
requested otherwise by me on the Patient Questionnaire.
PurelyCanadianDrugs shall be entitled to substitute a brand name
prescription drug with a generic prescription drug, where available, unless the
physician has indicated that there can be "no substitution" or dispensed as
written. ONCE PURCHASED AND SHIPPED, NO PHARMACEUTICAL PRODUCT MAY BE RETURNED
OR EXCHANGED.
PurelyCanadianDrugs 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. PurelyCanadianDrugs does not provide its agency or
attorney services as a substitute for healthcare or the advice of My Doctor.
PurelyCanadianDrugs 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. PurelyCanadianDrugs shall not accept
the return for use or re-use of any portion of any drug or non-prescription
medication (British Columbia College of Pharmacists Bylaw 5 (33 subsection.1).
I have read and understood all of the terms and conditions set out
in this Agreement for Services and agree, on behalf of myself, my heirs,
successors, executors, administrators and assign to be bound by these terms and
conditions.
Signed this ____ day of ________________________, 20____.
_________________________________________
(Signature)
Print Name Clearly: ________________________________________
D. AUTHORIZATION TO CANADIAN DOCTOR
I provide my consent and authorize any physician, licensed in
Canada and engaged by PurelyCanadianDrugs for the purposes set out herein, to obtain my
full medical history, drug history, contact information and other necessary
information and documentation from my U.S. physician. In this context, I
further consent to both the Canadian physician and my U.S. physician contacting
one another to discuss my medical condition and medical information and to
release any such medical information to each other, as such may be necessary or
appropriate to the prescribing of medication(s). I understand that the reason
for this consent is to provide the Canadian physician with a full opportunity
to conduct an independent analysis of whether the medications(s) prescribed by
my U.S. physician is appropriate, and discuss any potential medical
complications that may arise. I further understand that my medical information
will not be used for any other reason, and will be kept in strict confidence.
I further agree to regularly visit my U.S. physician(s) and to
promptly advise the Canadian physician of any changes to my medical condition
or prescriptions.
I have read and understood the terms and conditions set out in this
AUTHORIZATION TO CANADIAN DOCTOR above and I agree, on behalf of myself, my
heirs, executors, administrators, successors and assign to be bound by these
terms and conditions.
Signed this ____ day of ________________________, 20____.
_________________________________________
(Signature)
Print Name Clearly: ________________________________________
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