Generic Pharmacy c/o CanTrustRx Inc. | #7 - 2 Donald Street, Winnipeg, MB, Canada R3L 0K5| Phone 1:800-640-2221 | Fax: 1-800-640-5553

Generic Pharmacy is an division of CanTrustRX Limited

No prescription will be filled until a signed and dated copy of this document and a completed Patient Questionnaire has been received by CanTrustRx. These documents can sent be fax toll free to [1-800-640-5553]

THE UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY:

1. Represents and confirms CanTrustRx Inc., along with its subsidiaries and affiliates (herein collectively "CanTrust") that the pharmaceutical(s) to be delivered to the undersigned were prescribed by a doctor licensed to practice medicine in the country, state, or other applicable jurisdiction in which the undersigned resides, that the prescription(s) for the pharmaceutical(s) were lawfully obtained from that physician and that the pharmaceutical(s) will be used only as directed and only by the person for whom the pharmaceutical was prescribed.
2. Acknowledges that CanTrust and CanTrust’s employees and agents have relied on the information and documentation provided by the undersigned (including the Patient Questionnaire) and the undersigned represents and confirms that the undersigned has, to the best of his/her knowledge, fully disclosed all pertinent requested information and documentation to CanTrust. The undersigned undertakes to notify CanTrust of any changes to his/her physical or medical condition by providing an updated Patient Questionnaire.
3. Understands that it is the undersigned’s responsibility to have regular physical examinations by the U.S. licensed physician whose care he/she is under, including all suggested testing by said physician to ensure the undersigned has no medical problems, which would constitute a contradiction to him/her taking the medication(s) being prescribed.
4. Authorizes and appoints CanTrust, as his/her agent and his/her attorney for the limited purposes of taking all steps and signing all documents on behalf of the undersigned necessary to obtain a prescription in Canada for the prescription sent by the undersigned to CanTrust, to the same extent as the undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself, including, but not limited to, collecting personal health information regarding the undersigned directly from his/her prescribing physician or pharmacist and disclosing personal health information to CanTrust employees, agents and service providers, as required, for the limited purposes set out above.
5. Authorizes and appoints CanTrust as his/her agent and his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned necessary to package or repackage the pharmaceutical(s) and to deliver them to the undersigned, to the same extent as the undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself.
6. Authorizes and appoints CanTrust, as his/her agent and as his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned for shipping his/her prescribed pharmaceutical(s) to the undersigned as if the undersigned had shipped the prescribed pharmaceutical(s) to himself/herself to the undersigned’s address.
7. Understands and acknowledges that the pharmaceutical(s) will not be packaged in child protective packaging, unless requested by the undersigned on the Patient Questionnaire, and the undersigned releases and discharges CanTrust and CanTrust’s employees and agents, from any and all causes of action with respect to the late delivery, non-delivery or missed delivery of the pharmaceutical(s) sent to the undersigned.
8. Acknowledges and agrees that the undersigned initiated a consultation with CanTrust and that CanTrust is not located in the United States. The undersigned acknowledges that the pharmacists working for CanTrust and the physicians contracted by CanTrust on the undersigned’s behalf are located and licensed to practice medicine or pharmacy in Canada and that all treatment the undersigned is receiving from the said physician and pharmacist is being received in Canada.
9. Acknowledges and agrees that any and all agreements reached or contracts formed throughout the course of the relationship between the undersigned and CanTrust shall be deemed to be made in Manitoba, and accordingly shall be governed by the laws of the Province of Manitoba and the laws of Canada as applicable to such contracts and agreements.
10. Agrees that any dispute that arises between him/her and CanTrust, its affiliates, related companies, subsidiaries, parent company, officers, directors, employees or agents shall be governed by the laws of the Province of Manitoba and the laws of Canada applicable to contracts formed in Manitoba and the undersigned agrees that the Courts of the Province of Manitoba shall have sole and exclusive jurisdiction over any such dispute.
11. Understands that CanTrust shall be entitled to substitute a prescription drug with a generic drug, where available in accordance with the Manitoba Drug Standards and Therapeutics Formulary, unless the physician has indicated that there be "no substitution".
12. Acknowledges and understands that once purchased and shipped, no pharmaceutical product may be returned or exchanged.