Canada Medicose Discount Prescription Drugs - Online Canadian Pharmacy

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Patient Questionnaire and Personal Information Form

I understand that the following information is required by Canada Medicose and Canadian Licensed Physicians to review my medical information for the purpose of getting the same medicine from Canada as I have been getting from my own family physician.

Patient Information

Last Name	First Name
Address
City	Zip Code
State	Country
Phone	Fax
Email
Date of Birth	Weight	kgs

Sex	Smoker	Pregnant	Nursing
Male	Yes	Yes	Yes
Female	No	No	No

Allergy Information

Please indicate any known drug allergy or any other allergy:

Current Medication

Please indicate medication currently being taken:

Family History

High Blood Pressure		Yes No
Cancer (Breast, prostrate or any other)		Yes No
Diabetes, Thyroid or other endocrine disorders		Yes No
Heart or artery disease		Yes No
Lipid or cholestrol disorder		Yes No
Migraine headaches		Yes No
Any other		Yes No

Patient Current Medical Condition:

Blood Disorders	Yes	No
Known nutrition deficiency including minerals or electrolytes	Yes	No
Immune Disorders	Yes	No
Lipid or cholestrol disorder	Yes	No
Neurological disorders	Yes	No
Diabetes, thyroid or other endocrine disorders	Yes	No
Cancer	Yes	No
Poor wound healing	Yes	No
Heart disease including atheroscierosis, angina, heart failure or history of heart attack.	Yes	No
Renal or kidney disease	Yes	No
Drug allergies	Yes	No
Liver disease	Yes	No
Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome	Yes	No
Emotional disorders	Yes	No
Smoker	Yes	No
Glaucoma	Yes	No
Hyperlipidemia (high cholestrol)	Yes	No
Chemical dependency	Yes	No
Upper respiratory disorders	Yes	No
Surgery	Yes	No
Medications used in the last 12 months	Yes	No
Lung disorder (ie., asthma, emphysema)	Yes	No
Rheumatoid arthritis, lupus or connective tissue diseases	Yes	No
High blood pressure	Yes	No
Other illness not listed above.	Yes	No

Other Information

Any other information you would like to share with
Medicose:

Credit Card Information

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Please note that we only accept Visa and Master Cards.

Card Holder Name (as on card)
Card Holder Address
Card Holder City
Card Holder State / Province
Card Holder Zip / Postal Code
Card Holder Country
Credit Card Type		Visa Master
Credit Card Number
Credit Card Expiry		/
Card Holder Name (as on card)

Please read the disclaimer below and click on 'Submit' to continue or 'Reset' to cancel the process.

Canada Medicose Power of Attorney and Release Form

Definitions and Interpretations

For purpose of this Agreement, the following words and expressions shall have the meaning set forth below, except where the context otherwise required.

A1 : "I or me" means the patient who is seeking to have CanadaMedicose fill a prescription.

A2 : "Family Physician" means patient's local physician whose care the patient is under.

A3 : "Canadian Physician" means a licensed Canadian Physician who will review and approve my prescription.

A4 : "CanadaMedicose" means a service provided by a Canadian Licensed Pharmacy who is conducting pharmacy business in Canada.

A5 :  "Prescription" means your family physician's order for the preparation and administration of a drug which is requested to be filled at CanadaMedicose after review by Canadian Licensed Physician.

THE UNDERSIGNED BEING OVER THE AGE OF 21 HEREBY:

1.	I understand that it would be a violation of the law to present false information on my medical profile questionnaire for the purpose of obtaining prescription medicine. I agree to truthfully and to the best of my knowledge answer all of the questions on my medical profile questionnaire form.  I will be responsible for all the consequences, if I provide false information to Canada Medicose.

2.	I fully understand that Canada Medicose and its employees and agents have relied on the documentation and information provided by me to the best of my knowledge, I fully disclose pertinent requested information and documentation to Canada Medicose.

3.	I take fully responsibility to notify Canada Medicose for any changes to my medical and physical conditions by providing a updated my medical profile questionnaire form.  I also conform that that I have had a physical examination by the Family Physician whose care I am under within the last twelve months.  And I will continue my regular follow up visit to my Family Physician to ensure I have no medical problem which would constitute a contradiction to me by taking the medicine being prescribed for me.

4.	I give permission to Canada Medicose to collect my medical files, medical reports and any other relevant information as needed from my Family Physician for the purpose of prescribing my medication.  I also authorize Canada Medicose to perform medical consultation with my Family Physician, whose care I am under.  I understand that this will include reviewing my medical profile questionnaire and information submitted by me.

5.	I acknowledge and understand that Canada Medicose and Canadian Physician recommend regular physical examinations with my local US Physician (whose care I am under) for regular physical examination.  I also understand that Physician at Canada Medicose will only verify and prescribe medications that my Family Physician as already prescribed for me.  Canada Medicose will not provide my new medicine.  I also understand this consultation will not include a physical examination and I hereby waive a physical examination at this time.

6.	I understand that this service should not be considered a substitute for a healthcare provider and this service is not in anyway intended for the diagnosis of a medical condition. I understand that Canada Medicose will not make any medical diagnoses and should not be used as a substitute for professional medical advice. I will direct all questions to my Family Physician. I will consult my Family Physician before taking any new drug or changing my daily health regimen. I understand that any opinions, advice, statements, services, offers, or other information expressed or made available by third parties (including merchants and licensors) are those of the respective authors or distributors of such content.

7.	I will be responsible that I will immediately contact my Family Physician or any other Physician whose care I am under if I suffer any adverse effects while taking these prescribed medicine.  In case of such events, it will be my responsibility to inform my physician regarding all the medicine I have taken.

8.	I agree to release liability and hold blameless the pharmacy staff, physicians, directors, affiliate, employee, officers, representative and independent contractor of Canada Medicose from all causes of suites, action, liens, penalties, judgments, obligation, liabilities, losses, actual or threatened at any time by reason of relating to, actual or consequential damages, arising directly or indirectly out of any matter whatsoever related to the dispensing or prescribing of my prescription medication and their potential side effects if any.

9.	I understand and acknowledge that my medicine will not be packed in child protective container and the undersigned release this charges Canada Medicose and all employees and agents of Canada Medicose from all causes of action with respect to the late delivery, non delivery or partial or incomplete delivery of medicine send to undersigned.

10.	I agree that the Canadian Physician shall not be liable for any liability, claim, loss, damage or expense of any kind or nature caused directly or indirectly by any inadequacy, deficiency or unsuitability of the prescription issues by the Canadian Physician or the inadequacy, deficiency or unsuitability of the Canadian physician's review of my medical information.  In no event will the Canadian Physician be liable for responsible for any whatsoever, including, direct, indirect, putative, special or consequential damages, even if advised of the possibility thereof.

11.	I acknowledge that the pharmacists and physicians working for Canada Medicose are located and licensed to practice medicine or pharmacy in Canada and that any treatment I am receiving from the said physicians and pharmacists shall be deemed to be received by me in Canada and I understand  and agree that I initiated this contract with Canada Medicose and that it is not located in the United States.

12.	Agree that the courts of Manitoba, Canada, shall hear any dispute that arises between me and Canada Medicose that the courts of Manitoba, Canada shall have the sole and exclusive jurisdiction and that the law of Canada shall apply to any and all disputes that may arise.

13.	Canada Medicose reserves the right to change this disclaimer and the medical consultation form at any time. I should read this disclaimer every time I place a new order. I understand that Canada Medicose will substitute a prescription drug with a generic drug where available unless otherwise indicated.

14.	All prescription medicine request should accompany a prescription from my Family Physician and I have been using the requested medicine for at least one month under the supervision of my Family Physician.

15.	I understand that all prescription medicine once purchased and shipped will not be returned and exchanged.

This agreement represents the complete agreement between Canada Medicose and me. I have read and understood the above-referenced "Patient Disclaimer" and agree to all of the above terms.

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