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AGREEMENT FOR SERVICES
A. DISCLOSURE AND REPRESENTATIONS BY CUSTOMER:
I, the undersigned, acknowledge, represent and confirm to
BirthControlBuzz.com and to Coastal Canada Pharmacy (hereinafter collectively
referred to as " BirthControlBuzz ") that:
The prescription(s) that I submit to BirthControlBuzz for the
medications (referred to in this Agreement as "pharmaceuticals" or
"medications") described in the prescription were prescribed by a physician
("My Doctor") licensed to practice medicine in the country, state or other
applicable jurisdiction in which I reside or where I sought treatment and who I
personally consulted.
The prescription(s) were lawfully obtained by me from My Doctor.
I will continue to have my medical condition and my use of the
pharmaceuticals obtained through BirthControlBuzz monitored by My Doctor on a
regular basis as My Doctor may advise me.
I am engaging BirthControlBuzz for the sole purpose of obtaining
prescription medications at a lower price than in the country in which I
reside.
I am not seeking medical advice or medical treatment of any kind or
nature whatsoever from BirthControlBuzz nor am I relying upon any medical
information from BirthControlBuzz or from any of its employees, officers,
agents or any and all others acting through or for BirthControlBuzz.
I understand that neither BirthControlBuzz nor any of its
employees, officers agents and all others acting through or for it, nor anyone
that is acting on its behalf, is providing medical advice, treatment advice or
treatment of any kind whatsoever to me.
I will use any pharmaceuticals obtained for me by BirthControlBuzz
strictly according to the instructions provided by My Doctor.
The pharmaceuticals will only be used as directed and only by me.
I can make my own medical decisions according to the law of the
place where I reside.
The prescription(s) for the pharmaceuticals has not been altered in
any way nor has it been filled prior to submission to BirthControlBuzz.
I will immediately contact My Doctor in the event that I suffer any
side effects from any pharmaceuticals.
It is my responsibility to have regular physical examinations by My
Doctor including all testing to ensure that I have no medical problems which
would constitute a contradiction to me taking the pharmaceuticals.
BirthControlBuzz's employees and agents have relied on the
information and documentation that I have provided or will provide (including
the Patient Profile) and I represent and confirm that I have fully disclosed
all pertinent and relevant information and documentation to BirthControlBuzz. I
agree to promptly notify BirthControlBuzz of any changes to my physical or
medical condition by providing an updated Patient Profile.
I understand that:
Coastal Canada Pharmacy is duly licensed in the Province of British
Columbia, Canada and is located at #1006-7495 132nd Street, Surrey, British
Columbia, Canada (Phone: 604-598-4673; Fax: 604-598-8795). Coastal Canada
Pharmacy's pharmacy manager is Grace Lee. BirthControlBuzz is located at
Suite #2001, 7495 132nd Street, Surrey, British Columbia, Canada V3W 1J8 (Toll
Free Phone: 1-866-868-8850; Toll free fax: 1-866-732-0306). BirthControlBuzz
manager is Wendy Morris.
B. AUTHORIZATION AND CONSENT
I hereby authorize and appoint BirthControlBuzz, 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(s) in Canada that is the
equivalent of the prescription(s) for the pharmaceuticals that I have forwarded
to BirthControlBuzz, 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
BirthControlBuzz 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. The authorizations and consents that I am
providing to BirthControlBuzz commence on the date I have signed this agreement
and shall continue until I revoke them. I understand that I can revoke the
consents and authorizations I have granted to BirthControlBuzz at any time.
I hereby specifically acknowledge that I am aware that
BirthControlBuzz will be transmitting my personal health information by
electronic means (for example fax, secure internet) to its affiliates and
service providers including the Canadian physician retained by BirthControlBuzz
on my behalf to obtain the Canadian prescription(s). I understand that the use
of electronic means will enhance the efficiency and timeliness of processing my
order. I also understand that BirthControlBuzz, 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
BirthControlBuzz's transmission of my personal health information by electronic
means.
If I was directed to BirthControlBuzz's services through an
affiliate, intermediary or other healthcare service provider Herein called an
"intermediary") I hereby authorize BirthControlBuzz to release the following
data to such intermediary: a numerical identifier indicating that I was a
patient referred from that intermediary; 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 will agree to abide by the privacy
policies of BirthControlBuzz 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 BirthControlBuzz 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.
I authorize and appoint BirthControlBuzz as my agent and my
attorney for the purpose of taking all steps and signing all documents on my
behalf necessary for shipping my prescribed pharmaceuticals to me as if I had
shipped them myself to my own address.
I understand that BirthControlBuzz is located in Canada, not in the
United States. I also acknowledge that the pharmacists working for
BirthControlBuzz and the physicians contracted by BirthControlBuzz on my behalf
are located and licensed to practice medicine or pharmacy in Canada and that
all services that I receive from the Canadian pharmacy and the 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
BirthControlBuzz shall be deemed to be made in the Province of British
Columbia, Canada and accordingly shall be governed by the laws of the Province
of British Columbia, Canada and the laws of the Country of Canada.
I agree that any dispute that arises between me and
BirthControlBuzz, its affiliates, related companies, subsidiaries, parent
company, officers, directors, employees, agents and contractors shall be
governed by the laws of the Province of British Columbia and I agree that the
courts of the Province of British Columbia shall have sole and exclusive
jurisdiction over any such dispute.
If a problem arises, I understand that I may need to contact the
College of Pharmacists for the Province of British Columbia located at 200 -
1765 West 8 th Avenue, Vancouver, British Columbia, Canada (Phone 604-733-2440
or 1-800-663-1940; Fax: 604-733-2440 or 1-800-377-8129) to report my concern.
C. PURCHASE AND SALE TERMS
I hereby acknowledge, understand, authorize and agree that:
BirthControlBuzz may charge my credit card account for the pharmaceutical(s)
price(s) plus shipping (in US Dollars) as is posted on the BirthControlBuzz web
site on the date that BirthControlBuzz completes my order.
In the event my payment is not authorized, I understand that
BirthControlBuzz has the right to cancel my order. In such event
BirthControlBuzz will attempt to provide me with notice of such cancellation.
After an order has been sent to the pharmacy I may not cancel the order and the
sale is final. The pharmaceutical(s) will be packaged in child protected
packaging, unless requested otherwise by me on the Patient Questionnaire.
BirthControlBuzz shall be entitled to substitute a brand name
prescription drug with a generic prescription drug, where available, unless the
physician has indicated that there can be "no substitution" or dispensed as
written. ONCE PURCHASED AND SHIPPED, NO PHARMACEUTICAL PRODUCT MAY BE RETURNED
OR EXCHANGED.
BirthControlBuzz 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. BirthControlBuzz does not provide
its agency or attorney services as a substitute for healthcare or the advice of
My Doctor.
BirthControlBuzz 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. BirthControlBuzz
shall not accept the return for use or re-use of any portion of any drug or
non-prescription medication (British Columbia College of Pharmacists Bylaw 5
(33 subsection.1).
I have read and understood all of the terms and conditions set out
in this Agreement for Services and agree, on behalf of myself, my heirs,
successors, executors, administrators and assign to be bound by these terms and
conditions.
Signed this ____ day of ________________________, 20____.
_________________________________________
(Signature)
Print Name Clearly: ________________________________________
D. AUTHORIZATION TO CANADIAN DOCTOR
I provide my consent and authorize any physician, licensed in
Canada and engaged by BirthControlBuzz for the purposes set out herein, to
obtain my full medical history, drug history, contact information and other
necessary information and documentation from my U.S. physician. In this
context, I further consent to both the Canadian physician and my U.S. physician
contacting one another to discuss my medical condition and medical information
and to release any such medical information to each other, as such may be
necessary or appropriate to the prescribing of medication(s). I understand that
the reason for this consent is to provide the Canadian physician with a full
opportunity to conduct an independent analysis of whether the medications(s)
prescribed by my U.S. physician is appropriate, and discuss any potential
medical complications that may arise. I further understand that my medical
information will not be used for any other reason, and will be kept in strict
confidence.
I further agree to regularly visit my U.S. physician(s) and to
promptly advise the Canadian physician of any changes to my medical condition
or prescriptions.
I have read and understood the terms and conditions set out in this
AUTHORIZATION TO CANADIAN DOCTOR above and I agree, on behalf of myself, my
heirs, executors, administrators, successors and assign to be bound by these
terms and conditions.
Signed this ____ day of ________________________, 20____.
_________________________________________
(Signature)
Print Name Clearly: ________________________________________
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