Order Form

ExpressMedsCanada.to

Code: 100028

Ordering Guide

When form is completed, please send it (along with a copy of the doctor's prescriptions) by:
Fax: 1-866-793-2987, or
Email:ExpressMedsCanada.to

PLEASE FILL OUT ALL FIELDS COMPLETELY

Important! For optimal health and best results of any medication it is important to have had a physical examination in the past 12 months. Have you had one? Y___ N___ (If not, we will require that you schedule an appointment with your physician.)

PATIENT INFORMATION

______________________________________________________
Full Name

___________
Age

______________________________________________________
Address

___________
Date of Birth

_______________________________ ______________________
City Province/State

___________
Sex

______________ ___________________________________
Postal/Zip Code Email

___________
Height

( )_______________________ ( )__________________
Phone (Home) Phone (Work)

___________
Weight

ALTERNATE SHIPPING ADDRESS
_______________________________________________________
Alternate Shipping Address

_______________________		_________		________
City		Province/State		Postal/Zip Code

__________________________
Alternate Phone

SHIP TO:

Primary Address: ___
Alternate Address: ___

PHYSICIAN INFORMATION

__________________________________________
Primary Physician Name

__________________________________________
Phone

__________________________________________
Name of Clinic / Doctors Office

__________________________________________
Fax Number

_______________________________________		_______________________		_________		________
Address		City		Province/State		Postal/Zip code

Do you require child resistant containers for your medication? Y or N

Please indicate if you would like to receive counseling: Yes ____ No ____

_____________________________________________________		_______________________
Signature		Date

ExpressMedsCanada.to Code: 100028
Ordering Guide

Have you previously filled out a Medical Questionnaire? Yes _____ No ____ Not Sure ____

If YES are there any changes Yes (please specify) __________________________________________________ No __________
NOTE: It is only necessary to fill out the Questionnaire once a year, as long as there are no changes. Please indicate if you / your family has a history of any of the following:

Patient Family Medical History

1) Hypertension (high blood pressure)	Yes	No
2) Cardiovascular (heart or artery disease)	Yes	No
3) Lipid or cholesterol disorder	Yes	No
4) Diabetes, thyroid or other endocrine disorder	Yes	No
5) Cancer	Yes	No
6) Migraine Headaches	Yes	No
7) Other Illness	Yes	No

If you answered YES to questions 1 - 7, please explain in more detail, if necessary

Patient Medical History

1) High Blood Pressure	Yes	No
2) Heart or artery disease including atherosclerosis, angina, palpitation, heart failure or history of heart attack	Yes	No
3) Liver Disease	Yes	No
4) Renal or Kidney Failure	Yes	No
5) Cancer	Yes	No
6) Immune Disorders	Yes	No
7) Blood Disorders	Yes	No
8) Diabetes, thyroid, or other endocrine disorder, including insulin resistance	Yes	No
9) Lipid or cholesterol disorder	Yes	No
10) Smoker	Yes	No
11) Asthma or Emphysema	Yes	No
12) Neurological Disorders	Yes	No
13) Emotional Disorders	Yes	No
14) Poor Wound Healing	Yes	No

15) Rheumatoid arthritis, lupus, or connective tissue diseases	Yes	No
16) Any known nutrition deficiency including minerals and electrolytes	Yes	No
17) Edema (fluid retention)	Yes	No
18) Glaucoma	Yes	No
19) Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome	Yes	No
20) Surgery	Yes	No
21) Chemical Dependency	Yes	No
19) Other Illness Not Yet Noted	Yes	No

*Please indicate any known drug allergies you may have:
____________	____________	____________
____________	____________	____________
____________	____________	____________

If you answered YES to any of the above questions please elaborate in the box below (i.e., duration of illness, any treatment or surgery received, amount smoked and for how long)

I hereby confirm that the above information is true and accurate as of the date hereof.
_________________________________________ Patient's Full Legal Name (Print)		____________________________________________ Patient's Signature ____________________________________________ Date (Month/Day/Year)

ExpressMedsCanada.to Code: 100028
Ordering Guide

CURRENT MEDICATIONS

Please list all medications you are currently taking and the condition for which they are prescribed.

Medication & Strength	Daily dosage (eg.1 tab daily)	Condition
_______________________________	_______________________	________________________
_______________________________	_______________________	________________________
_______________________________	_______________________	________________________
_______________________________	_______________________	________________________
_______________________________	_______________________	________________________

MEDICATIONS BEING ORDERED TODAY
Medication	Strength	Quantity	Generics		Subtotal
_______________________	_____________	________	Yes	No	_______________
_______________________	_____________	________	Yes	No	_______________
_______________________	_____________	________	Yes	No	_______________
_______________________	_____________	________	Yes	No	_______________
_______________________	_____________	________	Yes	No	_______________
_______________________	_____________	________	Yes	No	_______________
(If your order does not fit on the space provided, please attach them on a separate sheet) Add Shipping					$8
				Total (US $)	$______________

PAYMENT INFORMATION:
VISA _____	MASTERCARD _____
Card Holder Name (on Card) ___________________________________________________
Card Holder Address ___________________________________________________
City	__________________	Country	__________________
Province/State	__________________	Credit Card Number	__________________
Postal/Zip Code	__________________	Credit Card Expiration	__________________ (eg. 11/06)
		* CVV2 # Number	__________________
* (required for credit card transactions - The CVV2 verification number is a 3-digit (MC & Visa) number printed on the back of your credit card. It appears on the right hand side of the card.)
Unless otherwise notified in writing, I hereby authorize ExpressMedsCanada.to to charge my credit card for the cost of all present and future medications ordered plus all associated shipping costs.

____________________________________
Signature

________________________________
Date (Month/Day/Year)

CUSTOMER AGREEMENT - CODE 100028

No prescription(s) will be filled until a signed and dated copy of this document and a completed Patient Profile have been received by ExpressMedsCanada.to

I, as the undersigned, being over the age of 18, hereby covenant, represent, warrant and confirm to, and acknowledge and agree with, ExpressMedsCanada.to and its affiliates, related companies, subsidiaries and parent company, and to the Prescription Processing Centre identified herein (if any), as follows:

Disclosure and Representations

The pharmaceutical(s) to be delivered to me were prescribed by a doctor licensed to practice medicine in the country, state
or other applicable jurisdiction in which I reside or where I sought treatment, and were lawfully obtained from that physician.

Any medication obtained for me by ExpressMedsCanada.to will be used strictly according to the instructions provided by the physician who prescribed the medication, and only by the person for whom the pharmaceutical(s) were prescribed.

I can make my own medical decisions according to the law of the place where I reside. The prescription(s) I am requesting ExpressMedsCanada.to to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to ExpressMedsCanada.to. I agree to immediately destroy all copies of my prescription(s) once it has been filled.

I am not seeking or relying on any medical information from ExpressMedsCanada.to or the Prescription Processing Centre, and I have
consulted a qualified physician licensed where I obtained the prescription within the last year.

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 ExpressMedsCanada.to.

I understand that it is my responsibility to have regular physical examinations by my primary US licensed physician that is responsible for my care including all suggested testing to ensure that I have no medical problems which would constitute a contradiction to me taking the medications being prescribed.

I acknowledge that ExpressMedsCanada.to's employees and agents have relied on the information and documentation that I am providing (including the Patient Profile) and I represent and confirm that I have fully disclosed all pertinent information and documentation to ExpressMedsCanada.to. I agree to notify ExpressMedsCanada.to of any changes to my physical or medical condition by providing an updated Patient Profile.

Authorization and Consent

I hereby authorize and appoint ExpressMedsCanada.to, 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 in Canada that is the equivalent of the prescription that I sent to ExpressMedsCanada.to, 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 ExpressMedsCanada.to 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.

I hereby specifically acknowledge that I am aware that ExpressMedsCanada.to and the Prescription Processing Centre 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 ExpressMedsCanada.to and the Prescription Processing Centre, as custodians 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 the transmission by ExpressMedsCanada.to and the Prescription Processing Centre of my personal health information by electronic means.

If I was directed to ExpressMedsCanada.to's services through the Prescription Processing Centre, or some other intermediary (for example Pharmacy Benefit Manager, Health Management Organization, or other healthcare service provider), I hereby authorize ExpressMedsCanada.to to release the following data to such an intermediary:

A numerical identifier indicating that I was a patient referred from that source; 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 ExpressMedsCanada.to 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 ExpressMedsCanada.to 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, and as if I had shipped the
prescribed pharmaceutical(s) to my own address.

I acknowledge and agree that I initiated a consultation with ExpressMedsCanada.to and that ExpressMedsCanada.to is not located in the United States. I also acknowledge that the pharmacists working for ExpressMedsCanada.to and the physicians contracted by ExpressMedsCanada.to on my behalf are located and licensed to practice medicine or pharmacy in Canada and that all services that I receive from any such Canadian physician and 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 ExpressMedsCanada.to shall be deemed to be made in the Province of Manitoba, Canada and accordingly shall be governed by the laws of the Province of Manitoba and the laws of Canada applicable to such contracts and agreements.

I agree that any dispute that arises between me and ExpressMedsCanada.to, its officers, directors, employees, agents and contractors shall be governed by the laws of the Province of Manitoba and the laws of Canada applicable to contracts formed in Manitoba, and I agree that the courts of the Province of Manitoba shall have sole and exclusive jurisdiction over any such dispute.

Purchase and Sale Terms

ExpressMedsCanada.to will charge my credit card the following amounts:

The medication price and shipping (in US dollars) as posted on the ExpressMedsCanada.to web site on the day ExpressMedsCanada.to receives my order; and in
the event my payment is not authorized, ExpressMedsCanada.to has the right to cancel my order and attempt to provide me with notice of
such cancellation.

The pharmaceutical(s) will not be packaged in child protected packaging, unless requested by me on the Patient Questionnaire.

ExpressMedsCanada.to shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available in accordance with the Manitoba Drug Standards and Therapeutic Formulary, unless the physician has indicated that there be "no substitution". That once purchased and shipped, no pharmaceutical product may be returned or exchanged.

ExpressMedsCanada.to 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.

ExpressMedsCanada.to does not provide its agency or attorney services as a substitute for healthcare or the advice of the customer's primary care physician.

ExpressMedsCanada.to 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.

The Prescription Processing Centre is acting as my agent in completing the forms and taking such other actions as are necessary to request ExpressMedsCanada.to to send me the prescriptions I am requesting, and is not the agent, express or implied, of ExpressMedsCanada.to. In this regard, but without limiting the generality of the foregoing, I acknowledge and agree that the Prescription Processing Centre does not have the authority to assume or create any obligation whatsoever, expressed or implied, in the name
of ExpressMedsCanada.to, or to otherwise bind ExpressMedsCanada.to in any manner whatsoever.

I have read and understood the terms and conditions set out in this Agreement and agree, on behalf of myself, my heirs, successors, administrators and assigns to be bound by these terms and conditions.

Signed this _______________ day of _______________, 2017.

________________________________________________ _______________________________________

(Signature) (Print Name) (Please Print Clearly)

Please check everything over carefully and remember to SIGN and DATE every page that you send to us.