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 1-866-921-2059.
You can also mail this information to our processing office using the
following address: Rx Trust Pharmacy, PO
Patient Information Form
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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: (
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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 ALL known drug allergies:
(if none, please mark none) |
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*Please indicate ALL medications currently
being taken: (also indicate strength
and frequency for each drug) |
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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 |
¡×
Emotional
mood disorders |
Yes |
No |
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¡×
Glaucoma or
other eye disorders |
Yes |
No |
¡×
Musculoskeletal
& Arthritic disorders |
Yes |
No |
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¡×
Respiratory
disorders (breathing problems) |
Yes |
No |
¡×
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 |
¡×
Blood
disorders |
Yes |
No |
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High lipids
and triglycerides |
Yes |
No |
¡×
Neurological
disorders |
Yes |
No |
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¡×
Stomach,
liver, intestinal disorders |
Yes |
No |
¡×
Dermatological
disorders |
Yes |
No |
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¡×
Renal or
kidney disease including prostate disease |
Yes |
No |
¡×
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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Order Information & Billing Authorization
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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 $12.95 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: |
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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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*Payment
Information |
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*How
would you like to pay for your medications? (Please make all money orders payable to Canada
Health Solutions Inc.) |
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____ Visa |
____ MasterCard |
____ American Express |
____ 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
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*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 cardholder, authorize Canada Health Solutions Inc., a
provider of prescription fulfillment services, to apply all applicable
charges to my credit card. 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
Canada Health Solutions 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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Client Agreement & Authorization
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 Canada Health Solutions
Inc. (¡°CHS¡±), a provider of
international prescription fulfillment services, by any customer or
client (¡°I¡± or ¡°me¡±) who is purchasing prescription medications (¡°Medications¡±) through CHS by
using the CHS prescription service.
I acknowledge and agree with CHS 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.
3.
I understand and acknowledge that Canada Health Solutions Inc. is NOT a pharmacy and that the
information and services provided by CHS
are strictly for the purposes of assisting me in filling a prescription
prescribed by a qualified physician licensed where I obtained the prescription.
4.
I acknowledge that CHS
is required to have a licensed Canadian Physician (the ¡°Canada MD¡±) review my medical information and that CHS 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 CHS. I hereby waive any requirement to have the Canadian Physician
conduct a physical examination of me. I acknowledge that there are no fees
charged to me arising from the Canadian Physician 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 CHS 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.
5.
I hereby give permission to My Own Physician to release any and all medical information and
data whatsoever which CHS, the Canadian Physician or the Canadian
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 CHS,
the Canadian Physician or the Canadian Pharmacist may contact My Own Physician
for more information.
6.
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.
7.
I AGREE THAT THE CANADIAN 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 PHYSICIAN OR THE INADEQUACY, DEFICIENCY OR
UNSUITABILITY OF THE CANADIAN PHYSICIAN¡¯S REVIEW OF MY MEDICAL INFORMATION. IN
NO EVENT WILL THE CANADIAN PHYSICIAN BE LIABLE OR RESPONSIBLE FOR ANY DAMAGES
WHATSOEVER, INCLUDING, DIRECT, INDIRECT, PUNITATIVE, SPECIAL OR CONSEQUENTIAL
DAMAGES, EVEN IF ADVISED OF THE POSSIBILITY THEREOF.
Authorization,
Consent and Power of Attorney
*
I hereby authorize and appoint Canada
Health Solutions Inc. and its agents, 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 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 CHS 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, and purchasing and arranging delivery of
the medications prescribed in the Canadian prescription.
*
I hereby consent to CHS, the Canada
MD and any licensed Canadian 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, payment and other information and verifying future
orders.
* I confirm that my personal information will be handled only by CHS order-processing employees and
contractors (including physicians and nurses, pharmacists and pharmacy
technicians) in accordance with CHS¡¯s
Privacy Policy, which may be updated from time to time.
*
I hereby acknowledge and understand that CHS will in all instances substitute
generic drug equivalents unless specified otherwise by My Own Physician or
myself. I also understand that CHS
will in all instances use Canadian drug equivalents, including generics, to
fill my order, and therefore brand names may vary.
*
I hereby specifically acknowledge that I am aware that CHS will be transmitting my personal health information by
electronic means (for example fax, secure internet) to its employees, agents,
affiliates and service providers including the Canadian 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 CHS, 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 CHS 's transmission of my personal
health information by electronic means.
*
If I was directed to CHS 's services
through an affiliate or intermediary (for example Pharmacy Benefit Manager,
Health Management Organization, or other healthcare service provider), I hereby
authorize CHS 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
CHS relating to the protection of my
personal health information. I specifically consent to the transmission of the
forgoing information by electronic means.
Client Agreement & Authorization -
continued
Disclosure
And Representations
* I represent that ALL of the following statements are true and agree that CHS and its employees and contractors
(physicians and nurses, pharmacists and pharmacy technicians) are relying on
these representations:
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 CHS to
assist me in obtaining was prescribed by a qualified physician licensed where I
obtained the prescription;
4.
The
prescription I am requesting CHS to
assist me in obtaining has not been altered in any way nor has it been filled
prior to submission to CHS. I agree
to immediately destroy all copies of my prescription once it has been filled;
5.
The
prescription I am requesting CHS 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 CHS, I will take the same
for at least 30 days immediately prior to
the date that I submit my order to CHS;
7.
I
am not violating any laws where I reside by placing this order;
8.
I
will use any medication obtained for me by CHS
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 CHS 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 CHS.
* Canada Health Solutions Inc. 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
* CHS will charge my credit card the
following amounts for each order: the TOTAL COST OF THE MEDICATIONS as
posted on the CHS Website on the day
CHS receives my order and SHIPPING AND HANDLING COST for each
package CHS ships.
* In the event my payment is not authorized, CHS has the right to cancel my
order and attempt to provide me with notice of such cancellation.
*
CHS will charge my credit card a $20
fee for each cancelled order
* CHS 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.
* CHS does not provide its agent or
attorney services as a substitute for health care or the advice of a physician.
* CHS 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 CHS and
its employees, officers, directors, delegates, agents 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 CHS
including, without limitation, any and all side effects whether previously
known or unknown;
2.
CHS 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