Patient Information: (Please Print Clearly)

Choose your dispensing pharmacy:

Choose the country or countries below that you will allow us to dispense your medication from. All of the pharmacies are licensed in the practice of pharmacy in the country they operate. Based on your decision our website will choose where to send your prescriptions based on product availability and/or price.

Personal Medical History: (Please Print Clearly)

Your Billing Information: (Please Print Clearly)

Authorization and Consent
· I hereby appoint CanadaRx 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 included in this order, 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 CanadaRx, the Canadian MD and any pharmacy supplying my order, 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 CanadaRx and its contractors 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 this order4. I will use any medication obtained for me by CanadaRx 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 CanadaRx and I have consulted a qualified physician licensed where I obtained the prescription within the last year;6. I will immediately contact the physician who provide my prescription included with this order in the event I suffer any unexpected side effects
Release and Waiver
I hereby release and save CanadaRx and 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 use of the medication obtained for me by CanadaRx including, without limitation, any and all side effects whether previously known or unknown;2. CanadaRx’s 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. My breach of any terms, conditions or representations or warranties in this agreement 
Governing Law
This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of Manitoba.

_________________________________              ______________________________    _____________________________ Signature                                                                  Print Name                                               Date