Canadian Prescription Service

PO Box 97176, Richmond Main Post Office

Richmond, BC, Canada V6Y 4H4

Toll Free Phone: 1-877-278-5355 · Toll Free Fax: 1-877-278-5359

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 FORM, and the CLIENT AGREEMENT & AUTHORIZATION FORM. Fax all completed forms and ORIGINAL PRESCRIPTIONS to us at 1-877-278-5359. You can also mail this information to our processing office using the following address: Canadian Prescription Service, PO Box 97176, Richmond Main Post Office, Richmond, BC, Canada V6Y 4H4. Please allow 8-12 business days from the day we receive your order for processing and delivery of your prescriptions. Orders are shipped using Canada Post and are fully insured against loss or damage.

Patient Information Form Page 1 of 4

* Indicates Mandatory Fields

OFFICE USE ONLY

AGENT ID:

ORDER ID:

*First Name:		*Last Name:						*Sex (M or F):
*Date of Birth: ____/____/____ (mm/dd/yy)		*Height: ________ Ft. ________ Inches						*Weight: ________ lbs
*Home Tel: ( )		*Secondary Tel: ( )					Fax: ( )
*Shipping Address: Street & Apt. # (PRINT CLEARLY)							Email Address:
*City:	*State:					*ZIP:	How did you hear about us?
Personal Medical Profile
*Primary Physician’s Name:					*Physician’s Tel: ( )
*Please indicate ALL known drug allergies: (if none, please mark none)
*Please indicate ALL medications currently being taken: (also indicate strength and frequency for each drug)
*Please indicate if you’ve ever experienced any of the following: (answer by circling YES or NO)
§ Smoker			Yes	No		§ Emotional mood disorders			Yes	No
§ Glaucoma or other eye disorders			Yes	No		§ Musculoskeletal & Arthritic disorders			Yes	No
§ Respiratory disorders (breathing problems)			Yes	No		§ Cancer			Yes	No
§ Heart disease: high blood pressure, heart disease, angina, heart failure, heart attack, arrhythmias or heart surgery.			Yes	No		§ Blood disorders			Yes	No
§ High lipids and triglycerides			Yes	No		§ Neurological disorders			Yes	No
§ Stomach, liver, intestinal disorders			Yes	No		§ Dermatological disorders			Yes	No
§ Renal or kidney disease including prostate disease			Yes	No		§ Other: Please specify below			Yes	No
§ Diabetes, thyroid or other endocrine disorders			Yes	No
*If you have answered YES to any of the above, please elaborate:
*Patient/Client Signature:						*Date: _______/_______/_______ (mm/dd/yy)

Order Information & Billing Authorization Page 2 of 4

* Indicates Mandatory Fields

*Medications Being Ordered
*Drug Name	Strength	Quantity	Generics (Y or N)		Price (USD)
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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 FREE.		Shipping & Handling:
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:
*Patient Consultation
*Do you require a pharmacist to contact you to provide patient counseling?				YES		NO
*Would you like us to contact your doctor to obtain prescriptions for this order?				YES		NO
*For additional discounts, would you like a Cheap Rx Membership at $34.95/yr?				YES		NO

*Payment Information
*How would you like to pay for your medications? (Make all money orders payable to Global Health Supplies)
____ Visa	____ MasterCard		____ American Express				____ Discover	____ Money Order
*Name on Credit Card:				*Credit Card Number:
*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)
*Cardholder Address: Street & Apt. # (If different from above)
*City:		*State:				*ZIP:
*Billing Authorization
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 United States dollars.
*Cardholder Signature:					*Date: ________/________/________ (mm/dd/yy)

Client Agreement & Authorization Page 3 of 4

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 Mosaic International Ventures Ltd. (“MIV”), a provider of international prescription fulfillment services, by any customer or client (“I” or “me”) who is purchasing prescription medications (“Medications”) through MIV by using the MIV prescription service. I acknowledge and agree with MIV 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 MIV partnered licensed Canadian and/or International pharmacy and that the information and services provided by MIV 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 MIV 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 MIV, its affiliates, contractors, and agents to facilitate the processing of my prescriptions through these countries.

2. I acknowledge that MIV is required to have a licensed Canadian and/or International Physician (the “Canada MD” and “International MD” respectively) review my medical information and that MIV 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 MIV. I understand and acknowledge that the International MD is a medical physician fully licensed in a country outside of Canada. I hereby waive any requirement to have the Canadian and/or International MD conduct a physical examination of me. I acknowledge that there are no fees charged to me arising from the Canadian and/or International MD reviewing my medical information. If there is any change to my physical or medical condition or any change in medications I am taking, I shall notify MIV of such changes by providing an updated patient profile and medical history questionnaire at the time I am ordering additional medications. I certify that I have had a physical examination by a doctor licensed to practice medicine in the country, state, or other applicable jurisdiction in which I reside (“My Own Physician”) within the last 12 months from the date hereof.

3. I hereby give permission to My Own Physician to release any and all medical information and data whatsoever which MIV, 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 MIV, 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 AND/OR INTERNATIONAL PHYSICIAN SHALL NOT BE LIABLE FOR ANY LIABILITY, CLAIM, LOSS, DAMAGE OR EXPENSE OF ANY KIND OR NATURE CAUSED DIRECTLY OR INDIRECTLY BY ANY INADEQUACY, DEFICIENCY OR UNSUITABILITY OF ANY PRESCRIPTION ISSUED BY THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN OR THE INADEQUACY, DEFICIENCY OR UNSUITABILITY OF THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN’S REVIEW OF MY MEDICAL INFORMATION. IN NO EVENT WILL THE CANADIAN AND/OR INTERNATIONAL PHYSICIAN BE LIABLE OR RESPONSIBLE FOR ANY DAMAGES WHATSOEVER, INCLUDING, DIRECT, INDIRECT, PUNITATIVE, SPECIAL OR CONSEQUENTIAL DAMAGES, EVEN IF ADVISED OF THE POSSIBILITY THEREOF.

6. I understand and acknowledge that MIV is not a pharmacy and does not provide any medical advice.  I further understand and acknowledge that MIV 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 Mosaic International Ventures Ltd. 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 MIV 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 MIV, the Canada and International MD, and any licensed Canadian and International Pharmacy supplying my order, col