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FOR THE NEW CUSTOMER: Thank you for your interest in our prescription service. In order to fill your prescription, we will require certain information from you, which includes:
Note: If you do not have a copy of your prescription, we will need your physician’s name, phone and fax number so that we may contact him to receive a copy of the prescription. Allow 2-3 weeks after receipt of order for delivery. Place Order: Step 1. Complete and Sign the:
Step 2. Send us your order.
Step 3. After you have sent your information to our office, call 604-687-2564 to ensure we have received your paperwork. T 604-687-2564 To enquire about the cost of your medication, email krippsrx@gmail.com All charges included in quoted price of prescription.
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PATIENT MEDICAL INFORMATION FORM (Please Print)
Your
Personal Information Street Address: ______________________________________________________________ City: ____________ State/Province_________ Zip Code: ________ Country: ___________ Work Phone: ____________ Home Phone: ______________ Best Time to Call _________ E-mail: _________________________ Date of Birth: _______________ Sex: ________ Height: __________ Weight: _________ You MUST answer ALL of the following QUESTIONS for your order to be FILLED. If not we cannot fill your prescription. Your Family Physician Information: Name: ______________________________________ Street Address: ______________________________________________________________ City: ___________ State/Province: __________ Zip Code: ________ Country: _________ Work Phone: _________________________ Home Phone: __________________________ Personal Medical Information Do you have a history of or any early findings suggestive of the following:
______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Please list all allergies and/or sensitivities? ______________________________________________________________ ______________________________________________________________ ______________________________________________________________
Please list all current medications.
Please indicate here if you will accept the generic version of the medication that you are requesting. Yes __________ No ___________
Yes ___________ No ____________
Drug name/Brand Amount Dosage I hereby confirm that all information provided is true and correct to the best of my knowledge and I consent that my Doctor can be contacted if additional medical information is required. Signed: ________________________________ Date: _________________________ RETURN BY MAIL TO:
CUSTOMER AGREEMENT FORM I,_____________________, of the City of _________________ in the state of _______________ in the Country of _______________have read, understand and agree to the following: AUTHORIZATION AND CONSENT DISCLOSURE AND REPRESENTATIONS I represent that all of the following statements are true and agree that Kripps Pharmacy Ltd. including its contractors or agents and all others acting through or for it are relying on these representations:
PURCHASE AND SALE TERMS Kripps Pharmacy Ltd. will charge my credit card the following amounts: the medication price (in U.S. dollars). All charges are included in the price of the medication. In the event my payment is not authorized, Kripps Pharmacy Ltd. has the right to cancel my order and attempt to provide me with notice of such cancellation. CanadaGlobalDrugs.com/Kripps Pharmacy Ltd. reserves the right to refuse to process any order in their sole discretion. Wherever possible Kripps Pharmacy Ltd. will substitute prescription drugs with lower cost generic drugs in non-child protective packaging. Kripps Pharmacy Ltd. will not exchange medication or return any monies paid once an order is filled. RELEASE AND WAIVER In consideration of approving this prescription and in consideration of Kripps Pharmacy Ltd. making this prescription, I agree not to sue CanadaGlobalDrugs.com/Kripps Pharmacy Ltd., its employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription. I hereby release and save CanadaGlobalDrugs.com/Kripps Pharmacy Ltd. including their employees and contractors and all others acting through or for it harmless from any and all suits, demands, liabilities, claims, actions, expenses, losses and damages of any kind whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation including reasonable attorneys’ fees arising from;
Nothing in this release shall be deemed to release Kripps Pharmacy Ltd. including its employees from compliance with the applicable pharmacy standards of practice under the Pharmacy Act of British Columbia. I hereby agree that the relationship between and the resolution of any and all disputes arising between me and CanadaGlobalDrugs.com and Kripps Pharmacy Ltd., employees, officers, agents and all others acting through or for it, be governed by and construed in accordance with the laws of the Province of British Columbia, Canada. I hereby acknowledge that the Courts of British Columbia shall have jurisdiction to entertain any complaints, demands, claims or cause of action, whether based on alleged breach of contract or alleged negligence arising from this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts in the Province of British Columbia. All of which is agreed. Printed Name of Patient: ______________________________________________________ Address: ___________________________________________________________________ Signature of Patient: ________________________ Date: ___________________________ Printed Name of Witness: ______________________________________________________ Signature of Witness: _______________________ Date: ____________________________ Address of Witness: __________________________________ ORDER FORM Your Family Physician Information: (Please provide information for your Primary Physician) Name _______________________________________________ It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one? ____ YES ____ NO Your Order
NOTE: ORIGINAL PRESCRIPTION AND PHOTOCOPY OF PHOTO IDENTIFICATION MUST BE SUBMITTED WITH THE ORDER (Faxed or Mail) Medication
Name on Card _______________________ Mailing Address ________________________________________________ I hereby authorize Kripps Pharmacy to apply applicable charges to my credit card for the cost of prescription drugs as noted above including refills on prescriptions submitted within 3 months. Name _______________________________ Signature ____________________________ I fully understand that the prices quoted include all fees. Kripps Pharmacy shall be entitled to substitute a prescription drug with a generic drug unless otherwise stated and Kripps Pharmacy will not use child protective packaging unless requested. Printed Name of Patient ______________________________________________________ Address __________________________________________________________________ Phone #_____________________________ Email ________________________________ Please allow approximately 2-3 weeks for delivery. Order one contingent upon 3 month supply.
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