Canadian Prescription Service
Toll Free Phone:
How To Place Your Order: New Customer
Application
STEP 1:
Obtain a prescription from your physician for the medications you would like to
order. For maximum savings, we recommend
you order in bulk, therefore have your doctor write you a one year
prescription in the form of a 3 month supply and 3 refills for EACH medication. If
you prefer, we can contact your doctor to obtain the prescriptions on your
behalf.
STEP 2: Complete and sign the Patient Information Form,
the ORDER INFORMATION & BILLING AUTHORIZATION
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* Indicates Mandatory Fields |
OFFICE USE
ONLY |
AGENT ID: |
ORDER ID: |
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*First Name: |
*Last Name: |
*Sex (M or F): |
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*Date of Birth:
____/____/____ (mm/dd/yy) |
*Height:
________ Ft. ________ Inches |
*Weight:
________ lbs |
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*Home Tel: ( ) |
*Secondary Tel:
( ) |
Fax: (
) |
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*Shipping
Address: Street & Apt. # (PRINT
CLEARLY) |
Email
Address: |
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*City: |
*State: |
*ZIP: |
How did you
hear about us? |
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Personal
Medical Profile |
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*Primary
Physician’s Name: |
*Physician’s
Tel: ( ) |
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*Please
indicate |
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*Please
indicate |
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*Please
indicate if you’ve ever experienced any of the following: (answer by circling
YES or NO) |
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Smoker |
Yes |
No |
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Emotional
mood disorders |
Yes |
No |
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Glaucoma or
other eye disorders |
Yes |
No |
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Musculoskeletal
& Arthritic disorders |
Yes |
No |
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Respiratory
disorders (breathing problems) |
Yes |
No |
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Cancer |
Yes |
No |
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Heart
disease: high blood pressure, heart disease, angina, heart failure, heart
attack, arrhythmias or heart surgery. |
Yes |
No |
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Blood
disorders |
Yes |
No |
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High lipids
and triglycerides |
Yes |
No |
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Neurological
disorders |
Yes |
No |
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Stomach,
liver, intestinal disorders |
Yes |
No |
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Dermatological
disorders |
Yes |
No |
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Renal or
kidney disease including prostate disease |
Yes |
No |
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Other:
Please specify below |
Yes |
No |
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Diabetes,
thyroid or other endocrine disorders |
Yes |
No |
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*If you have answered YES to any of the above, please
elaborate: |
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*Patient/Client Signature: |
*Date: _______/_______/_______ (mm/dd/yy) |
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* Indicates Mandatory Fields
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*Medications Being Ordered |
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*Drug Name |
Strength |
Quantity |
Generics (Y or N) |
Price (USD) |
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8. |
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Shipping and handling fees
are $14.95 per package for prescription orders under $450. For prescription orders over $450 and/or
new husband and wife orders sent together, shipping is |
Shipping &
Handling: |
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All
orders come with our optional Insurance Plus Plan, which provides 100%
guaranteed expedited coverage
against loss or damage of packages.
This additional coverage is valued at $2.95 (per $500 value) and is
not yet included in your order total.
To not add our expedited coverage plan to your order, please
write “NO” in the space provided: ________ |
Order Total: |
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*Patient Consultation |
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*Do you require a pharmacist to contact you to
provide patient counseling? |
YES |
NO |
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*Would you like us to contact your doctor to obtain
prescriptions for this order? |
YES |
NO |
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*For additional discounts, would you like a Cheap Rx Membership
at $34.95/yr? |
YES |
NO |
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*Payment Information |
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*How would you like to pay for your medications? (Make all money orders
payable to Global Health Supplies) |
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____ Visa |
____ MasterCard |
____ American Express |
____ Discover |
____ Money Order |
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*Name on Credit Card: |
*Credit Card Number: |
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*Credit Card Verification Number: (The verification number is a 3-digit
number printed on the back of your card. It appears after and to the right of
your card number on the signature field.) |
*Card Expiry Date: _____/_____ (mm/yy) |
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*Cardholder Address: Street & Apt. # (If
different from above) |
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*City: |
*State: |
*ZIP: |
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*Billing Authorization |
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I, the undersigned card/account holder, authorize Global
Health Supplies, a provider of administration and billing services for Canadian Prescription Service, to apply
all applicable charges to my credit card/account. These charges include the
total cost of the drugs ordered, including refills on prescriptions submitted
within 90 days, and any applicable shipping and handling fees, which are
applied to each package Global Health Supplies ships me. I understand that a 90-day supply of each
medication will be shipped, unless otherwise specified. I also understand that generic
substitutions will be made when available, unless otherwise specified, and
that all prices and dollar amounts are in |
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*Cardholder Signature: |
*Date:
________/________/________ (mm/dd/yy) |
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This Client Agreement and Power of Attorney, also known
as Client Agreement and Authorization, (this “Agreement”), consisting of two (2) pages, must be signed, dated and
delivered to CheapRXMeds.com(“CRX”), a provider of international prescription fulfillment services, by
any customer or client (“I” or “me”) who is purchasing prescription
medications (“Medications”) through CRX
by using the CRX prescription
service. I acknowledge and agree with CRX as follows:
1.
If
placing this order as a customer, I, on behalf of myself, my heirs, assigns and
successors, hereby agree to all of the following terms and conditions,
represent that I understand all of the following terms and conditions and that
I have had adequate opportunity to consult any advisors necessary, whether
medical, legal or otherwise.
2.
If
I am placing the order on behalf of someone else, I represent that I have all
necessary consent, permission and authorization to do so on behalf of that
person and their heirs, assigns and successors and the person I represent
agrees to all of the following terms and conditions, understands all of the
following terms and conditions and has had an adequate opportunity to consult
any advisors necessary, whether medical, legal or otherwise.
In the case of paragraph 1 above, if I do not agree with all of the following
terms and conditions, I agree that I will not place any orders. In the case of paragraph 2 above, if I do not
have that person’s consent, permission or authorization or that person does not
agree with all of the terms below, I agree that I will not place any orders.
1.
I understand and acknowledge that all prescriptions,
including all prescription dispensing and patient medication consultation
services, are being provided by a CRX
partnered licensed Canadian and/or International pharmacy and that the
information and services provided by CRX
are strictly
for the purposes of assisting me in filling a prescription prescribed by a
qualified physician licensed where I obtained the prescription. Furthermore, I understand and acknowledge
that the medications I order through CRX
may be dispensed and shipped by a licensed pharmacy located in a country
outside of Canada (each referred to as an “International
Pharmacy”) and that these countries can include Australia. I further
acknowledge that I have been made expressly aware of the specific country or
countries my medication order(s) will be processed, dispensed and shipped from,
and that I voluntarily consented and authorized CRX, its affiliates, contractors, and agents to facilitate the
processing of my prescriptions through these countries.
2.
I acknowledge that CRX
is required to have a licensed Canadian and/or International Physician (the “Canada MD” and “International MD” respectively) review my medical information and
that CRX and its delegates, employees and
contractors have relied on the information and documentation provided by me and
I represent that I have fully disclosed all pertinent requested information and
documentation to CRX. I understand and acknowledge that the International MD is a
medical physician fully licensed in a country outside of
3.
I hereby give permission to My Own Physician to release any and all medical information and
data whatsoever which CRX, the Canadian and/or International Physician
or Pharmacist shall request for the purpose of performing a medical review to
determine whether the Medications prescribed by My Own Physician are
appropriate in the circumstances. I understand that this will include reviewing
the medical questionnaire and information submitted by My Own Physician and that
CRX, the Canadian and/or International Physician or Pharmacist may
contact My Own Physician for more information.
4.
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 contradiction to me taking medications prescribed by
My Own Physician. I agree that should I suffer any adverse affects while taking
any prescription medication that I will immediately contact My Own Physician
and that in the event I come under the care of another physician, I will inform
him or her of any and all medications that I have been prescribed.
5.
I AGREE THAT THE CANADIAN
6.
I
understand and acknowledge that CRX is not a pharmacy and does not provide any
medical advice. I further understand and acknowledge that CRX is a
referral and escrow service established to help me obtain my medications from a
licensed pharmacy.
Authorization,
Consent and Power of Attorney
*
I hereby authorize and appoint CheapRXMeds.com and its agents, affiliates, employees and
contractors 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
from a licensed Medical Doctor in Canada or other country that is the
equivalent of the prescription included in this order, 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 CRX employees,
agents, affiliates, contractors, and service providers including the Canadian
and/or International Physician being retained on my behalf, as required, for
the limited purpose of obtaining the Canadian and/or International
prescription, and purchasing and arranging delivery of the medications
prescribed in the Canadian and/or International prescription.
*
I hereby consent to CRX, the Canada
and International MD, and any licensed Canadian and International Pharmacy
supplying my order, collecting my personal and medical information, maintaining
the information necessary to quickly process future orders which may include
retaining on file my name, address, phone number, medical information, payment
and other information and verifying future orders.
* I confirm that my personal and medical information will be handled only by CRX order-processing employees and
contractors (including physicians and nurses, pharmacists and pharmacy
technicians) in accordance with CRX’s
Privacy Policy, which may be updated from time to time.
*
I hereby acknowledge and understand that CRX
will in all instances substitute generic drug equivalents unless specified
otherwise by My Own Physician or myself.
I also understand that CRX will in all instances use Canadian or
International drug equivalents, including generics, to fill my order, and
therefore brand names may vary. I
understand and acknowledge that International drug equivalents refer to drug
equivalents from countries outside of
*
I hereby specifically acknowledge that I am aware that CRX will be transmitting my personal health information by electronic
means (for example fax, secure internet) to its employees, agents, contractors,
affiliates and service providers including the Canadian and/or International
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 CRX, 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 CRX's transmission
of my personal health information by electronic means.
*
If I was directed to CRX's services
through an affiliate or intermediary (for example Pharmacy Benefit Manager,
Health Management Organization, or other healthcare service provider), I hereby
authorize CRX to release the
following data to such an intermediary:
a.
a
numerical identifier indicating that I was a patient referred from that source;
b.
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
CRX relating to the protection of my
personal health information. I specifically consent to the transmission of the
forgoing information by electronic means.
Disclosure
And Representations
* I represent that
1.
I
am of the age of majority or older where I reside;
2.
I
can make my own medical decisions according to the law of the country, state,
or other applicable jurisdiction where I reside;
3.
The
prescription I am requesting CRX to
assist me in obtaining was prescribed by a qualified physician licensed where I
obtained the prescription;
4.
The
prescription I am requesting CRX to
assist me in obtaining has not been altered in any way nor has it been filled
prior to submission to CRX. I agree
to immediately destroy all copies of my prescription once it has been filled;
5.
The
prescription I am requesting CRX to assist me in obtaining is not more
than one year old from the date the prescription was originally written;
6.
With
respect to any of the medications which
I now or hereinafter order from CRX, I will take the same for at least
30 days immediately prior to the date
that I submit my order to CRX;
7.
I
am not violating any laws where I reside by placing this order;
8.
I
will use any medication obtained for me by CRX
strictly according to the instructions provided by the physician who prescribed
the medication;
9.
I
am placing this order for medication for my sole use and I will not provide any
quantity of this medication to any other person;
10.
I
am not seeking or relying on any medical information from CRX and I have consulted a qualified physician licensed where I obtained
the prescription within the last year; and
11.
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 CRX.
12.
In
the event that my order is filled by a CRX partner pharmacy that does not
require me to provide a prescription for the products being ordered, I
acknowledge that I have received all necessary medical authorization and
approval from a qualified medical doctor licensed in the state in which I
reside to legally place such an order and to use the products being
ordered. I further acknowledge that my health and my use of the products
ordered is being closely monitored by a licensed medical doctor and that I have
and continue to receive all necessary professional medical advice on my current
and future use of such products.
* CheapRXMeds.com
has made no representations or warranties to me, including, without limitation,
representations or warranties with respect to any delivered medications’
usefulness or fitness for a particular purpose (including, without limitation,
its appropriateness for curing or helping relieve any particular ailment,
illness or disease, or its potential or actual side or adverse effects whether
previously known or unknown).
Purchase And
Sale Terms
* CRX, through its contracted
billing services provider Global Health Supplies, will charge my credit card
the following amounts for each order: the TOTAL
* In the event my payment is not authorized, CRX has the right to cancel my order
and attempt to provide me with notice of such cancellation.
*
CRX, through its contracted billing
services provider Global Health Supplies, will charge my credit card a $30 fee
for each cancelled order.
* CRX 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.
* CRX does not provide its agent or
attorney services as a substitute for health care or the advice of a physician.
* CRX 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.
Release And Waiver
* I hereby release and save CRX and
its employees, officers, directors, delegates, agents, affiliates and
contractors (including physicians and nurses, pharmacists and pharmacy
technicians) harmless from any and all suits, demands, liabilities, claims,
actions, expenses, losses and damages of any kind or nature whatsoever,
including, without limitation, general, direct, special, indirect and
consequential damages and costs of litigation (including reasonable attorney
fees) arising from:
1.
my
use of the medication obtained for me by CRX
including, without limitation, any and all side effects whether previously
known or unknown;
2.
CRX or its contractors’
manner or timeliness of completing any actions I have authorized above,
including, without limitation, their manner or timeliness in prescribing the
appropriate strength, dosage, or dispensing generic drugs and
non-child-protective packaging; and
3.
my
breach of any terms, conditions or representations or warranties in this
agreement.
Nothing in this release shall be deemed to release any CRX pharmacy or pharmacist contractors from compliance with the
applicable standards of practice or usual professional duties and obligations,
which a pharmacist owes.
* If any term or
provision of this agreement is determined to be invalid or unenforceable by any
court, such determination shall not invalidate the rest of this agreement which
shall remain in full force and effect as if the invalid term or provision had
not been made part of this agreement.
Governing Law
* I agree that any and all agreements reached or contracts formed throughout
the course of the relationship between me and CRX 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 and the laws of Canada
applicable to such contracts and agreements.
I, the client, have read, understood and
agree to all of the foregoing in this two (2) page document entitled ‘Client Agreement & Power of Attorney’.
Client
Printed Name
___________________________________________
Client Signature
_________________________________________
Date
(Day/Month/Year)
________________________________________