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No prescriptions
will be filled without a signed and dated copy of this form.
The undersigned, (hereinafter the
“Client”) confirms that:
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| 1. |
The Client
is of the age of majority in the jurisdiction in which the
Client ordinarily resides (“Place of Residence”).
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| 2. |
The Client is not restricted
from making his or her own medical decisions under the laws
of the Place of Residence of the Client. |
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| 3. |
The Client confirms to
Federal Drugs (hereinafter “The Provider”) that
the pharmaceutical(s) ordered by the Client (“the
Ordered Product(s)”) were prescribed by a duly qualified
medical practitioner in the Place of Residence of the Client
after a personal examination by the prescribing physician
necessitating the need for the Ordered Product(s) for the
Client's specific diagnosed medical condition. |
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| 4. |
The Client has not violated
any laws in the Place of Residence of the Client, in obtaining
the prescription for the Ordered Product(s). |
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| 5. |
The Client confirms that
the Ordered Product(s) will not be used in any way whatsoever,
except as prescribed by the duly qualified medical practitioner
who originally issued the Prescription to the Client (“The
Client’s Physician”) and that the duty of care
is the responsibility of the
Client’s Physician. |
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| 6. |
The Client confirms that
no person other than the Client will use the Ordered Product(s). |
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| 7. |
The Client confirms that
he or she did not seek or request a medical opinion of the
Canadian licensed co-signing physician regarding the strength,
dosage, usefulness or qualities of the Ordered Product(s)
or the duration of use, frequency of use, or appropriateness
for their particular
medical condition, nor do they seek any medical advise in
any way from the Canadian co-signing physician. |
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| 8. |
The Client releases and
discharges The Provider, and all of their officers and directors,
agents, and employees from any and all liability, claims
or causes of action with respect of the use or application
of the Ordered Product(s) by the Client, including, but
not limited to undesired
side effects. |
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| 9. |
The Client confirms the
release in the preceding paragraph also benefits and protects
any Canadian Physician retained by The Provider to lawfully
issue the prescription in Canada as directed by the Client’s
Physician. |
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| 10. |
The Client agrees that
child protective packaging may not be used by The Provider
and the Client releases and discharges The Provider and
all of their officers and directors, agents and employees
from any and all causes of action with respect errors or
omissions by the company
or agency responsible for transporting the Ordered Product(s)
to the Client. |
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| 11. |
The Client grants Limited
Power of Attorney to The Provider, for the limited purpose
of signing any documents as required by the laws of the
Province of Manitoba (Canada), which are necessary to permit
the delivery of the Ordered Product(s) to the Client, in
the same manner as the Client could, if the Client had personally
attended at the Provider place of business in Winnipeg,
Manitoba, Canada. |
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| 12. |
The Client attorns to the
jurisdiction of Manitoba and agrees that any dispute that
arises between the Client and the Provider shall be heard
by the courts in Manitoba, Canada. The Provider and Client
hereby submit to the jurisdiction of Manitoba and agree
that any dispute shall be heard by the Courts in Manitoba,
Canada, including, but not limited to any claims of negligence
and/or malpractice. Further, the Client agrees that the
laws of Manitoba, Canada shall apply in such a proceeding,
agrees to these provisions on the basis that the Client
under stands that he/she is actively doing business in Manitoba,
Canada pursuant to the laws, policies and privileges of
Canadian law including but not limited to the laws of Manitoba,
Canada and that the Client is benefiting from such laws,
policies and privileges by participating in this program. |
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| 13. |
The Client acknowledges
that the Ordered Product(s) may not be returned for a refund
or an exchange. |
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| By signing this
document the client confirms that he/she has read and understood
these terms and that they are true and correct and the client
agrees that the terms herein are binding on the client and
the heirs assigns, successors and personal representatives
of the client. |
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| Signature |
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Print
Name |
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Date |
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