Online Medical Profile Form

Complete all sections and sign where necessary. This will be required only the first time you register with us.

MedicalForm

YOUR PERSONAL INFORMATION

YOUR MEDICAL PROFILE

Have you had a physical exam in the last (12) months?
Are you pregnant (or) nursing?
Are you a smoker?
Do you have any known allergies (incl. drug allergies)?

MEDICAL HISTORY

Please select all conditions that apply to you:

COUNTER MEDICATIONS

Please list all prescriptions and over the counter medications that you are currently taking. The pharmacy can only provide appropriate care if information provided is accurate and complete.
(e.g. Lipitor 20mg)
(e.g. “1 tablet once daily”)

UPLOAD PRESCRIPTION(S)

Maximum file size: 33.55MB

Allowed File Types: JPG, JPEG, PNG, DOC, DOCX, PDF

PAYMENT

(Payment is due at the time that the order is placed)
PAYMENT METHOD:
Please make your check of choice out to: TCP International

Maximum file size: 33.55MB

Allowed File Types: JPG, JPEG, PNG, DOC, DOCX, PDF

CUSTOMER AGREEMENT

The undersigned, (hereinafter the “Client”) being over the age of 21, hereby agrees that:

  1. I am not legally restricted from making my own medical decisions and grant Canadian Meds, its pharmacy network, affiliates, agents, related companies, subsidiaries, and parent companies (hereinafter the “Providers”) a power of attorney for the limited purpose of signing any document required by Canadian authorities to permit the delivery of the ordered products to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.
  2. I confirm the prescription submitted was lawfully obtained from a physician licensed to practice within my place of residence, that the prescription is for my personal use, that the prescription has not been altered or filled prior to submission and that the medications will only be used as re-prescribed by a licensed Canadian physician who will reissue the prescription, if deemed appropriate.
  3. I affirm that, to the best of my knowledge, I have fully and truthfully disclosed all pertinent information and documentation to the Providers and that the Providers have only relied on and will continue to rely on the information provided by my physician and me. I accept that I am responsible for notifying the Providers of any change in my medical profile and authorize the providers to communicate with my physician if they so seem it advisable. I affirm that the Provider’s review of my medical information is for the sole purpose of verifying the providers to communicate with my physician if they so deem it advisable. I affirm that the Provider’s review of my medical information is for the sole purpose of verifying the appropriateness of the prescription and is not intended to diagnose any medical condition nor is it a substitute for my duty to consult my physician.
  4. I affirm that I have been taking the prescribed medication for at least 30 days prior to submission, that I have had a medical examination in the past twelve months, that I will continue being monitored by my physician and that I will promptly contact my physician in the event of adverse effects from the use of pharmaceuticals.
  5. I understand the medications will be dispensed in their original manufacturer’s packaging or in child resistant package, unless specified.
  6. I agree that once shipped, no medications may be returned for refund or exchange and that orders canceled before shipping will be charged US $130.00 per prescription plus the price of the medication.
  7. I release and discharge the Providers, its officers, directors, employees and agents of any and all liabilities, claims and causes of action with respect to error, omissions, negligent acts or misrepresentations by my physician and the Canadian physician except as appropriate and usual when pharmaceuticals are provided, and also for the late delivery, non-delivery or missed delivery of the products by the company or agency responsible for transportation. I further agree that the Canadian physician shall not be liable for any liability, claim, loss, damage or expense caused directly or indirectly by any inadequacy, deficiency or unsuitability of the Canadian physician’s review of my medical information and original prescription nor on the re-issue of the prescription.
  8. I acknowledge and agree that I am using Canadian Meds for the sole purpose of helping me comply with the documentation and communication necessary to service my request. I understand Canadian Meds is not a pharmacy and is not the seller and handler in any form or manner of prescription drugs and does not provide medical advice.
  9. I agree that any dispute that arises between me and the Providers shall be governed by the laws of the province of British Columbia and agree that the courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such dispute.
  10. I have read and understood the terms and conditions set out in this Customer Agreement and agree, on behalf of myself, my heirs, successors, administrators and assigns, to be bound by these terms and conditions.