Patient Profile Form

Gender: | Male | Female | Date of Birth: | D | D | M | M | Y | Y | Y | Y |

DRUG ALLERGIES AND/OR MEDICAL CONDITIONS :

CURRENT MEDICATIONS :

(prescription and over-the-counter)

SHIPPING / MEMBER INFORMATION:

(If not Patient)

Day Phone: | | | | - | | | | - | | | | | Evening Phone: | | | | - | | | | - | | | | |

Cell Phone: | | | | - | | | | - | | | | | Fax: | | | | - | | | | - | | | | |

Email:

PHYSICIAN INFORMATION :

Day Phone: | | | | - | | | | - | | | | | Evening Phone: | | | | - | | | | - | | | | |

Cell Phone: | | | | - | | | | - | | | | | Fax: | | | | - | | | | - | | | | |

Email:

FAMILY AND CORPORATE PLAN INFORMATION:

Canadian Pharmacy Choice, 33 Coldwater Crt., Thornhill, Ontario, L4J 7S4

Phone Toll Free: 1-866-817-5145 Local: 1-416-217-2727

Fax Toll Free: 1-866-327-8364 Local: 1-416-217-0199

APPOINTMENT WAIVER AND RELEASE:

I hereby appoint Canadian Pharmacy Choice and its delegates or contractors as my agent and attorney for the purpose of obtaining a prescription from a Medical Doctor in Canada (the “Canadian MD”) which corresponds to the prescription(s) included in my order(s), which 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 Canadian Pharmacy Choice , the Canadian MD and any pharmacy supplying my orders, collecting my personal and medical information, maintaining the information necessary to quickly process future orders which may include retaining on file my name, address, phone number, payment and other information and verifying future orders.

DISCLOSURE AND REPRESENTATIONS:

I represent that all of the following statements are true and agree that Canadian Pharmacy Choice and its contrac tors are relying on these representations:

1. I am 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. I am not violating any laws where I reside by placing orders;

4. I/The Patient will us e any medication obtained for me/him/her by Canadian Pharmacy Choice strictly according to the instructions provided by the physician who prescribed the medication;

5. I am not seeking or relying on any medical information from Canadian Pharmacy Choice and I/The Patient have/has personally consulted a qualified physician licensed where I/he/she obtained the prescription within the last year;

6. I will immediately contact the physician who provided the prescription(s) included with my/The Patient’s order(s) in the event I/he/she suffer(s) any unexpected side effects.

RELEASE AND WAIVER:

I hereby release and save Canadian Pharmacy Choice, its employees and contractors 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 arising from:

1. My/The Patient’s use of the medication obtained for me/him/her by Canadian Pharmacy Choice including, without limitation, any and all side effects whether previous ly known or unknown;

2. Canadian Pharmacy Choice or its contractors’ manner or timeliness of completing any actions I have authorized above, including, without limitation, in prescribing the appropriate strength, dosage, or dispensing generic drugs and non -child -protective packaging;

3. Breach of any terms, conditions or representations or warranties in this agreement.

Sign date and send this form to:

33 Coldwater Crt.
Thornhill, Ontario, L4J 7S4

Phone: 1-866-817-5145 Fax: 1-866-327-8364

| D | D | M | M | Y | Y | Y | Y |

Date Print Name Signature