Who will the prescription be for?
First Name: _________________________________ Last Name: _________________________________
Street Address: _________________________________ City: _________________________________
State: _______________ Zip: _______________
Email Address: ___________________________
Yes, send me the CMM newsletter via email containing special offers, promotions and health info (FREE)
Tel: (       ) ________________ Fax: (       ) ________________ Business: (       ) ________________
Date of Birth: (dd/mm/yyyy) ___________ Height: (ft/in) ___________ Weight: (pounds) __________
Gender: male female
Have you had a physical examination in the last 12 months? Yes No

(to process your order, it's mandatory to have had a physical examination in the last 12 months)
Please check any current medical conditions and illnesses that apply to you
Heart Condition or Blood Pressure
Yes No
Angina
Arrhythmia
Atrial Fibrillation
Heart Attacks
Congestive Heart Failure
High Blood Pressure
Mitral Valve Disease
Stroke (CVA)
Other __________________________ __________________________
Respiratory Condition
Yes No
Allergic Rhinitis
Asthma
Chronic Bronchitis
Emphysema
Other __________________________ __________________________
Diabetes, Thyroid, Endocrine Condition
Yes No
Diabetes Type 1
Diabetes Type 2
Hyperthyroidism
Hypoglycemia
-->
Hypothyroidsim
Thyroid Disease
Other
__________________________ __________________________
High Cholesterol
Yes No
If Yes, diagnosed at what age: _______________
Is it a common problem in your family?
Yes No
High Triglycerides
Other
__________________________ __________________________
Colon or Prostate Disorders
Yes No
Benign Prostatic Hypertrophy
Colon Disorders
Other
__________________________ __________________________
Gastrointestinal
Yes No
Acid Reflux/Gerd
Hiatal Hernia
Stomach Ulcers
Rectal Bleeding
Lactose Intolerance
Black Stools
Ulcerative Colitis
Crohn's Disease
Irritable Bowel Syndrom
Other
__________________________ __________________________
Eye Disorders
Yes No
Glaucoma
-->

Cataracts
Retinal Problems
Other __________________________ __________________________

Other Medical Conditions
Yes No
Acne
AIDS
Anemia
Eczema/Psoriasis
Smoking
Amount per day ____________
How many years ___________
Alcohol
(How often_____________)
Menopause
Pregnancy
Blood Disorders
Herpes Simplex
Obesity
Sleeping Pills/ Tranquilizers
Other __________________________ __________________________
Cancer
Yes No
If yes, please specify type: __________________________ __________________________
Neurological or Psychological
Yes No
Anxiety
Attention Deficit disorder (ADD)
Bipolar disorder
Depression
Insomnia
Panic Disorder
Epilepsy
Parkinson
Other __________________________
 
Muscle, Bone or Joint Disorder Yes No
Arthritis
Back/Spine Disorders
Gout
Osteoporosis
Other
__________________________ __________________________
Chronic Illness
Yes No
Chronic Fatigue Syndrome
Firbromyalgia
Chronic Pain
Multiple Sclerosis
Other
__________________________ __________________________
Kidney or Liver Disorders
Yes No
Renal (kidney) failure
Require dialysis
Hepatitis
Cirrhosis of the Liver
Other
__________________________ __________________________
If you answered YES to any of the above questions please elaborate in the area below (i.e. duration of illness, any treatment or surgery received)
__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
(include your parents and siblings)
Diabetes, Thyroid or other endocrine disorder
Yes No
Relationship _______________
Breast Cancer
Yes No
Relationship _______________
Hypertension (high blood pressure)
Yes No
Relationship _______________
Cardiovascular (heart or artery disease)
Yes No
Relationship _______________
Lipid (cholestoral) Disorder
Yes No
Relationship _______________
Prostate Cancer
Yes No
Relationship _______________
Other forms of Cancer
Yes No
Relationship _______________
Migraine Headaches
Yes No
Relationship _______________
Other illnessess not previously noted:
Please list any pills or medications you are CURRENTLY taking (drugs, natural or herbal supplements, vitamins and all other forms of medication):
__________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________
Please list all known allergies below (including drug allergies):
__________________________ __________________________ __________________________ __________________________ __________________________ __________________________
 
1
CREDIT CARD (recommended for fastest delivery service) Credit Card Number ______________________
Please use this credit card information for my future prescription orders. Expiry Date ____ / ____
Visa Mastercard
Name of cardholder _______________________ Cardholder Signature X ___________________
2
Money Order: I will send a money order for each prescription order that I place. Referred by
Do you have a promotional code number? ______________ Where did you hear about us? ______________
 
The customer consent and waiver form is for you to read, date and sign. This form is a document containing the terms and conditions of joining our program. This form is used to ensure that you understand program rules such as...
• You are not a minor in the place that you reside
• That you are not going to share your medications with anyone filled by the pharmacy
• That we are not allowed to accept returns of medications
• That you will not reuse your prescription form once your medications have been filled by the pharmacy
• That you understand that your US physician is your primary care physician . And that Canada Medicine Mart is an agent that sends your medications
 
ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS AND SUCCESSORS, I 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.
 
AUTHORIZATION AND CONSENT
• I hereby appoint Canada Medicine Mart, a division of Pharma Group USA Ltd. ("CMM"), its delegates and contractors as my agent and attorney for the purpose of obtaining a prescription from a Medical Doctor in Canada (the "Canada MD") which corresponds to the prescription included in this order. The steps to obtain a prescription from the Canada MD may include directly contacting my prescribing physician, and purchasing and arranging delivery of the medications prescribed in the Canadian prescription, substantially on the terms set forth below, all to the same extent I could if I personally took such steps.
• I hereby consent to CMM, the Canada MD and any pharmacy supplying my order, collecting my personal and medical information, maintaining the information necessary to quickly process future orders and 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 CMM's order-processing employees and contractors (including physicians, nurses, pharmacists and pharmacy technicians) which may be updated from time to time.
DISCLOSURE AND REPRESENTATIONS
I represent that all of the following statements are true and agree that CMM and its contractors (physicians, 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 place I reside;
3. The prescription I am requesting CMM to assist me in obtaining was prescribed by a qualified physician licensed where I obtained the prescription;
4. The prescription I am requesting CMM to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to CMM. I agree to mail in original prescription and understand it is null and void once faxed into CMM unless not filled by CMM.
5. I am not violating any laws where I reside by placing this order;
6. I will use any medication obtained for me by CMM strictly as prescribed by the duly qualified medical practitioner who originally issued the prescription to me.
7. 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;
8. I am not seeking or relying on any medical information from
CMM and I have consulted a qualified physician licensed where I obtained the prescription within the last year.
 
9. I will immediately contact the physician who provided my prescription included with this order in the event that I suffer any unexpected side effects from any medication obtained for me by CMM.
10. CMM 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).
11. I understand that the Canada MD with CMM is not my treating physician, has not established a physician-patient relationship with me, and has not provided any medical treatment or advice to me, nor has the Canada MD independently prescribed medication for me for any medical condition, and especially the medical condition that the prescription to be filled by CMM is intended to treat. I also understand that the limited role of any Canada MD is solely to facilitate the delivery of prescription medication from CMM as ordered by my regular treating physician, and the Canada MD has no duty to independently determine whether any prescribed medication is appropriate for the treatment of my medical condition. I agree to look exclusively to my regular treating physician should any medical issues related to my medical condition or the prescription arise. In the event that I am seeing a Canadian & American licensed physician (dual doctor) in the United States then it is understood that CMM acts solely as the agent to facilitate the delivery of prescription medications as written by the dually-licensed physician.
RELEASE AND WAIVER
I, hereby release and save CMM and its employees and contractors (including CMM 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 CMM including, without limitation, any and all side effects whether previously known or unknown;
2. CMM's 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. Injury or illness, including death, arising from the fact that the prescription prescribed by my regular treating physician was not the appropriate medication, or was prescribed in an inappropriate dosage, for the treatment of my condition; and
4. My breach of any terms, conditions or representations or warranties in this agreement. Nothing in this release shall be deemed to release any CMM pharmacy or pharmacist contractors from compliance with the applicable standards of practice or usual professional duties and obligations, which a pharmacist owes.
PURCHASE AND SALE TERMS
The Canadian pharmacy will charge my credit card the following
amounts: the medication price, SHIPPING COST for each order CMM ships and any applicable taxes.

In the event my payment is not authorized, CMM has the right to cancel my order and attempt to provide me with notice of such cancellation.

CMM 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.

CMM does not provide its agent or attorney services as a substitute
for health care or the advice of a physician.

CMM 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.
GOVERNING LAW
This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of the Province of Alberta, Canada.

I have read and understood all of the foregoing.

Signed this ____ day of _________,
200__
Applicant Signature:

X ____________________________
Print Name of Applicant:
(Please print clearly):

X ____________________________
Signature of Witness:

X ____________________________
Print Name of Witness:

X ____________________________