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AGREEMENT FOR SERVICES
A. DISCLOSURE AND REPRESENTATIONS BY CUSTOMER:
I, the undersigned, acknowledge, represent and confirm to CanadaMedShop.com and to York Pharmacy (hereinafter collectively
referred to as "CanadaMedShop.com") that:
The prescription(s) that I submit to CanadaMedShop.com 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 CanadaMedShop.com monitored by My Doctor on a
regular basis as My Doctor may advise me.
I am engaging CanadaMedShop.com 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 CanadaMedShop.com nor am I relying upon any medical
information from CanadaMedShop.com or from any of its employees, officers, agents
or any and all others acting through or for CanadaMedShop.com.
I understand that neither CanadaMedShop.com 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 CanadaMedShop.com
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 CanadaMedShop.com.
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.
CanadaMedShop.com'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 CanadaMedShop.com. I agree to
promptly notify CanadaMedShop.com of any changes to my physical or medical
condition by providing an updated Patient Profile.
I understand that:
B. AUTHORIZATION AND CONSENT half, as required, for the
limited purpose of obtaining the Canadian
prescription. The authorizations and consents
that I am providing to CanadaMedShop.com 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 CanadaMedShop.com at any time.
I hereby specifically
acknowledge that I am aware that CanadaMedShop.com 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 CanadaMedShop.com 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 CanadaMedShop.com, 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 CanadaMedShop.com's
transmission of my personal health information
by electronic means.
If I was directed to CanadaMedShop.com's
services through an affiliate, intermediary or
other healthcare service provider Herein called
an "intermediary") I hereby authorize CanadaMedShop.com 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 CanadaMedShop.com 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 CanadaMedShop.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
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 CanadaMedShop.com 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 CanadaMedShop.com is located
in Canada, not in the United States. I also
acknowledge that the pharmacists working for CanadaMedShop.com
and the physicians contracted by CanadaMedShop.com 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 CanadaMedShop.com 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 CanadaMedShop.com, 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:
CanadaMedShop.com may charge my credit card account for
the pharmaceutical(s) price(s) plus shipping
(in US Dollars) as is posted on the CanadaMedShop.com web
site on the date that CanadaMedShop.com completes my
order.
In the event my payment is not
authorized, I understand that CanadaMedShop.com has the right
to cancel my order. In such event CanadaMedShop.com 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.
CanadaMedShop.com 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.
CanadaMedShop.com 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. CanadaMedShop.com
does not provide its agency or attorney services
as a substitute for healthcare or the advice of
My Doctor.
CanadaMedShop.com 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. CanadaMedShop.com 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 CanadaMedShop.com 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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