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207 - 1425 Marine Drive
West Vancouver, BC
Canada V7T 1B9
Customer Order Form
Toll-Free Phone: 1-800-794-8552
Toll-Free Fax: 1-866-868-2303 |
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Customer Information (Shipping Address) |
| Full Name: ___________________________________________________________________________ |
| Date of Birth (____/_____/______) Gender:
Female
Male |
| Street Address: ________________________________________________________________________ |
| City: ______________________________ State: ____________
Zip Code: _________________________ |
| Home Phone: ___________________________ Work/Mobile Phone:
______________________________ |
| Email Address: ________________________________________________________________________ |
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Are you requesting prescriptions for a minor (under 18 years
of age) or you are actively acting as the customer's care giver?
Name & Relationship: _______________________________________ Phone:
_________________ |
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Medications You Are Ordering |
| Ordering from Prescription Point is easy and affordable!
We make every effort possible to provide you with the lowest priced options
for filling your prescriptions. |
| Medication & Strength |
Directions |
QTY |
Generic
Allowed (Y/N) |
Refills |
Price |
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| Total |
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Shipping Options
$9.99 - Canada / Multi-Location Shipping ***
$5.99 - Shipping From United States Pharmacy Only
*** If ordering Canadian prescriptions and United States generics in
the same order, only $9.99
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Credit Card Information And Authorization
TO PAY BY CASHIERS CHECK or MONEY ORDER, mail payment and order to the
appropriate address (see page 3). Please make payment to Prescription
Point. If you have any questions regarding payments, call toll-free 1-800-794-8552.
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| Method Of Payment:
MasterCard
Visa
Money Order/Cashier's Check |
| Card Number: __________________________________________
Expiry Date ______/________ |
| Cardholder's Signature: ___________________________________
Date Signed: _____________ |
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Customer Information (Billing Address) |
| Full Name: ____________________________________________________________________ |
| Street Address: _________________________________________________________________ |
| City: ____________________________ State: ____________ Zip
Code: ____________________ |
| Home Phone: _______________________ Work/Mobile Phone: ___________________________ |
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Physician Information |
| Doctor's Name: ________________________________________________________________ |
| Doctor's Street Address: _________________________________________________________ |
| City: ___________________________________ State:______________
ZIP: _______________ |
| Doctor's Telephone: ____________________________________________________________ |
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Customer Health Information |
| Have you had or do you suffer from any of the following
medical conditions? (Check all that apply) |
Smoker
Glaucoma
Upper Respiratory Condition
High Cholesterol
Stomach, Liver, Intestine Condition
Renal or Kidney Disease
Thyroid or Diabetes
Arthritis |
Emotional Disorder
Cancer
Neurological Disorder
Blood Disorder
Heart Disease / Attack
Stroke
High Blood Pressure |
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Drug Allergy, Interaction & Dispensing |
| Do you have any known drug allergies:?
Yes
No |
How would you like your medications dispensed from our pharmacies? PLEASE
CHECK ONE |
| If yes, please specify: _______________________________ |
Original Manufacturer's Packaging
Easy Open Caps / Non-Safety Caps
Safety Caps (Childproof Caps) |
| ________________________________________________ |
|
| Please list all medications you are currently taking but are not currently
ordering: __________________________________ |
Please fill my prescriptions with GENERICS, when available, to save
more money:
Yes
No |
| _________________________________________________ |
|
| Would you like a pharmacist to call you to provide patient
counseling or to answer any questions you may have?
Yes
No |
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Non-Safety Cap Authroization |
Prescription Point requires that all prescriptions must
be dispensed using SAFETY CAPS unless the patient requests otherwise.
If you would like your prescriptions dispensed using non-safety caps,
please sign below. I request that these prescriptions and all refills
of these prescriptions NOT be dispensed in special child-resistant containers.
Signature: X_____________________________________ Date Signed: ____________________ |
|
Prescription Point Consent and Waiver of Liability |
1. I believe the medical history information
provided to be true to the best of my knowledge. I, also, understand and
acknowledge, Prescription Point, with my best interests in mind, may use
and disclose the minimum information necessary for treatment, payment,
or health care operations. This includes - planning my care and treatment,
communication with other health officials who contribute to my care, billing
operations, and assessing health care quality and reviewing the competence
of health care professionals.
2. When filling my medications through Prescription Point’s Canadian
and International pharmacies, I authorize Prescription Point to take all
steps, sign all documents and to act on my behalf as if I were personally
present and acting myself for the limited purposes of (a) obtaining a
Canadian and/or International prescription for any prescription which
I have sent Prescription Point; and/or (b) packaging my prescriptions
and delivering them to me.
3. I am not seeking medical advice or treatment of any kind whatsoever
in coming to Prescription Point and its physicians, employees, officers,
agents and all others acting through or for it.
4. Neither Prescription Point, nor any of its physicians, employees, officers
agents and all others acting through or for it, or anyone that is acting
on its behalf, is providing medical advice, professional advice, treatment
advice or treatment of any kind whatsoever to me.
5. I am coming to Prescription Point for the SOLE PURPOSE OF OBTAINING
A PRESCRIPTION. I understand that no one on behalf of Prescription Point
will take any steps whatsoever to determine whether the prescription is
appropriate. Title to my medications passes from Prescription Point to
me when my medications leave Prescription Point’s affiliated pharmacies.
6. I hereby acknowledge that this prescription was originally prescribed
by an American doctor and that I will continue to have my medical condition
and medications monitored by my doctor.
7. I have given the authority to Prescription Point to act as my agent
and/or representative to facilitate the purchase of prescription medicine
from licensed pharmacies, filled by licensed pharmacists.
8. In consideration of approving this prescription and in consideration
of Prescription Point fulfilling this prescription, I agree not to sue
Prescription Point, its employees, officers, agents and all others acting
through or for it, and release Prescription Point, its employees, officers,
agents and all others acting through or for it, from all legal liability
for any problems associated with the prescription.
9. I hereby agree that the relationship between and the resolution of
any and all disputes arising between me and Prescription Point, its employees,
officers, agents and all others acting through or for it, shall be governed
by and construed in accordance with the laws of the State of Washington,
U.S.A. I hereby acknowledge that the Courts of the State of Washington
shall have jurisdiction to entertain any complaints, demands, claims or
cause of action, whether based on alleged breach of contract or alleged
negligence arising out of the signing of this prescription, and I hereby
agree that I submit irrevocably to the exclusive jurisdiction of the Courts
of the State of Washington.
This agreement shall apply to every sale by Prescription Point to me and
may not be altered unless in writing and signed by both Prescription Point
and me. I HAVE READ AND UNDERSTAND THESE TERMS AND AGREE THAT THEY SHALL
BE BINDING UPON ME AND MY ASSIGNS, HEIRS AND PERSONAL REPRESENTATIVES.
Order cancellation charge of $20 will apply to any order, once that order
has been processed and before it has shipped. Medical history information
on this form is effective on the date signed and shall expire in one year
or when the information becomes inaccurate. I understand that I am ordering
from an international pharmacy and that once the pharmacy ships my medications,
ALL SALES ARE FINAL. We are unable to take returns. I understand that
prices are SUBJECT TO CHANGE without prior notice. When placing an order,
please call to receive current pricing. |
| Customer Signature: X________________________________________
Date: ___________________ |
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Placing Your Order By Fax, Telephone |
Placing Your Order By Mail |
Ready to place your order? Simply FAX your form along with any prescriptions
to our toll-free fax: 1-866-868-2303. Please contact
us toll-free at 1-800-794-8552 about 30 minutes after
faxing to confirm that we have received your order.
If you have any questions, feel free to contact toll-free at 1-800-794-8552. |
If you do not have access to a fax machine or are paying by cashier's
check or money order, you have the option of mailing in your valid US
physician's prescriptions.
Prescription Point
207 - 1425 Marine Drive
West Vancouver, BC
Canada V7T 1B9 |