Chester Clinic

 

Youdrugstore.com

Fax: 1-877-448-5539 359 Johnson Ave. West Unit E Winnipeg, MB, Canada, R2L 0J2 www.youdrugstore.com [email protected] Patient Order Form
YOUDRUGSTORE.COM PATIENT MEDICAL PROFILE
Please fax these forms toll free to 1-877-448-5539-
*** Note: Your original prescription(s) must be mailed to us unless they are faxed from your physician's office. Patient Information
(Asterisk (*) Indicates required information. Please print clearly.)
*First Name
*Last Name
*Phone (day)
Phone (Evening)
*Date of Birth (MM/DD/YY)
Fax Number
Would you like a reminder when it's time for a refill?
Information about your Primary Physician:
*Physician's Full Name
*Phone (day)
Phone (Evening)
Fax: 1-877-448-5539 359 Johnson Ave. West Unit E Winnipeg, MB, Canada, R2L 0J2 www.youdrugstore.com Medical Information
ALL medical information MUST be completed!) (Attach additional sheet if required)
MEDICAL CONDITIONS: (Please indicate ALL medical conditions that you "currently" have and
include comments on the lines below)
Alzheimer's Disease
Epilepsy
Diabetes (describe below)
High Blood Pressure
High Cholesterol
Arthritis – Rheumatoid, Osteoarthritis
COPD—Bronchitis & Emphysema
Liver Disease
Heart Disease (describe below)
Parkinson's Disease
Cancer (describe below)
HIV/AIDS
Tobacco use (smoker?)
Depression
Glaucoma
Thyroid Disorders
Kidney/Renal Disease
Comments:
DRUG ALLERGIES: (Please list ALL of the DRUG allergies that you currently have.)
A.C.E. Inhibitors – E.g. Vasotec
HMG-COA Reductase – E.g. Zocor
Beta Adrenergic Blockers – E.g. Inderal
Hydantoins – E.g. Dilantin
Calcium Channel Blockers – E.g. Diltiazem
Macrolides – E.g. Erythromycin
Carbamazepine – E.g. Tegretol
NSAID's – E.g. Naprosyn, Aspirin
Cephalosporins – E.g. Keflex
Penicillins – E.g. Augmentin
Cox-2 Inhibitors – E.g. Celebrex
Proton Pump Inhibitors – E.g. Prilosec
Glucocorticoids – E.g. Prednisone
Tetracyclines – E.g. Doxycycline
Histamine H2 Inhibitors – E.g. Zantac
Selective Serotonin Reuptake Inhibitors
– E.g. Prozac
Sulfonamides – E.g. HCTZ, Septra,
Celebrex, Glyburide
PLEASE LIST SPECIFIC DRUGS TO WHICH YOU HAVE HAD A REACTION:
Fax: 1-877-448-5539 359 Johnson Ave. West Unit E Winnipeg, MB, Canada, R2L 0J2 www.youdrugstore.com Please list below any prescription drugs or herbal medications you are currently taking: (Please
attach extra sheet if additional space is required)
Drug Name
Dosage Used How Long
For What Medical Condition
Comments:
Medication
For medication(s) that you wish to order, please enter the quantity, and listed price, as obtained through our web site or custom enter. An original prescriptioStre
your doc QT
office is r P
Medication
Strength
SHIPPING
All medications are shipped in child-protective packaging. Would like an additional vile with non-safety caps for easy
opening? Yes _ No _
At the time of you place an Order, you will be given the opportunity to allow for generic drug substitution if available, unless otherwise specified in by your prescribing physician. Patient Counselling - Request for Contact Our dispensing pharmacy offers counselling to al of its
patients. Do you want to receive counsel ing? Yes _ No _
If Yes when would be a good time for the pharmacist to contact you for counsel ing?
Payment Options
Credit Card
Master Card
Cardholder Address Credit Card Number Credit Card Expiry (MM/YY) Note: For prescriptions dispensed your credit card statement will show a charge from You Prescription Services Corp. Depending on how your Order is filled, more than one charge may appear on your credit card statement.
Fax: 1-877-448-5539 359 Johnson Ave. West Unit E Winnipeg, MB, Canada, R2L 0J2 www.youdrugstore.com Option 1: Contact my Doctor*
Option 2: Mail Your Prescription
Please mail your prescription and this form to: You! Drugstore 359 Johnson Ave. West Unit E Winnipeg, MB, Canada, R2L 0J2 Please list the medications you would like us to call your doctor for, or to transfer from another pharmacy Drug Name
Strength
Directions
* Contacting your Doctor and transferring from another pharmacy is only available to residents of the United States and Canada First Time Patients - Please fill out this section if you are a first time patient, or to update your information.
Secondary Contact
Full Name of Secondary Contact Relationship to You Your Physician
Primary Physicians Name Clinic Name and Street Address Referral Program (complete to earn credits for yourself and the
person who referred you)
Full Name of person who referred you YOUDRUGSTORE.COM CUSTOMER AGREEMENT
(Version 1.0 effective January 1, 2011)
I, as the undersigned, being over the age of 21, hereby enter into this agreement (the "Agreement") with You!Drugstore, for on
and on behalf of itself and each Dispensing Pharmacy (defined below), intending to be legally bound:
I am delivering this Agreement to You!Drugstore because I wish to place an order ("My Order") for certain
medications ("My Medications"), on the terms and conditions set out herein.
I WANT TO PURCHASE MY MEDICATIONS FROM, AND HAVE MY ORDER FILLED BY, A LICENSED
PHARMACY IN CANADA.
I confirm, acknowledge and agree that if, as part of the Order process, I have indicated that: I want to purchase my Medications from, and have My Order filled by, a pharmacy in more than one of the
listed countries (all countries selected by me are referred to hereafter as a "Selected Country"), You!
Drugstore will, as my agent, select a licensed pharmacy (each, a "Dispensing Pharmacy") from one or
more of the Selected Countries to dispense My Medications. You!Drugstore will, as my agent, make the de-
cision about which one or more Dispensing Pharmacy will dispense My Medications based on the availability
and/or price of My Medications in the Selected Countries; and
I want to purchase My Medications from, and have My Order filled by, a Dispensing Pharmacy in a specificSelected Country, My Medications will be dispensed by a Dispensing Pharmacy in that Selected Countryselected for me by You!Drugstore, as my agent.
I understand that You!Drugstore is not a pharmacy, and that in every case, I am purchasing My Medications from the Dispensing Pharmacy, and My Medications will be shipped directly to me by the Dispensing Pharmacy. If My Medica-tions are being purchased from pharmacies in different countries, they will be shipped directly to me by the Dispens-ing Pharmacy in that country. I confirm, acknowledge and agree that if My Medications are shipped to me from more than one Selected Country, I will be charged a separate shipping fee for each Selected Country. I further acknowledge that each Dispensing Phar-macy will make reasonable efforts to jointly ship My Medications and those of any other person who resides at my same address in the same package, however there is no guarantee that this will occur and therefore I confirm, ac-knowledge and agree that I and any other person who resides at the same address may each be charged a shipping fee for our medications. I specifically confirm, acknowledge and agree that title to My Medications passes to me from the Dispensing Phar- macy when My Medications leave the Dispensing Pharmacy, and that (subject expressly to Sections 1.04 above and 1.9 of Schedule "A" attached) any and all agreements reached or contracts formed throughout the course of my pur-chase of My Medications are and shall be deemed to be made in respect of any of My Medications that are pur-chased in a Selected Country, in that Selected Country and accordingly shal be governed by the laws of that Se-lected Country applicable to such contracts and agreements. I specifical y confirm, acknowledge and agree that (subject expressly to Sections 1.04 above and 1.9 of Schedule "A" attached) any dispute that arises between me and You!Drugstore or any of My Agents (defined below) shall, insofar as such dispute relates to any of My Agents located in a Selected Country, be governed by the laws of that Selected Country applicable to contracts formed in that Selected Country and the courts of that Selected Country shall have sole and exclusive jurisdiction over any such dispute. The additional Terms and Conditions set out on Schedule "A" hereto, which Schedule is hereby incorporated herein by reference, form an integral part of this Agreement, and I acknowledge having read such terms and conditions and that I agree to them. I HAVE READ AND UNDERSTOOD THE TERMS AND CONDITIONS SET OUT IN THIS AGREEMENT
(INCLUDING SCHEDULE "A" ATTACHED) AND AGREE, ON BEHALF OF MYSELF, MY HEIRS,
SUCCESSORS, ADMINISTRATORS AND ASSIGNS, TO BE BOUND BY THESE TERMS AND
CONDITIONS.
Signed this day of , 20 _
Signature of Witness Please print Witness name clearly Please print name clearly Schedule "A" ADDITIONAL TERMS AND CONDITIONS
PART I - AUTHORIZATIONS AND CONSENTS
1.1 The authorizations, appointments, powers of representation and consents that I am providing herein to You!Drugstore and My Agents
commence on the date I sign the Agreement and will continue until I cancel them. I understand that I can cancel the authorizations, ap-
pointments and consents I have herein granted at any time.
1.2 I hereby authorize and appoint You!Drugstore and My Agents as my agents and attorneys for the limited purpose of taking all steps
and signing all documents on my behalf necessary to obtain an Equivalent Prescription (defined below), if required by law in a Selected
Country from which I am purchasing My Medications, to the same extent as I could do personally if I were present taking those steps and
signing those documents myself. This authorization includes, but is not limited to: collecting Personal Information (defined below) about me;
collecting similar information from My Doctor (defined below) or pharmacist; and disclosing my Personal Information to You!Drugstore's
employees, agents, contractors, subcontractors, affiliates and service providers, including without limitation any Agent Physician (defined
below), You! Health Services Limited Partnership, any Dispensing Pharmacy and any pharmacist in a Selected Country being engaged on
my behalf (collectively, "My Agents"), as required, for the limited purpose of obtaining the Equivalent Prescription and for My Order to be
filled.
1.3 In this Agreement, the term:
(a) "Equivalent Prescription" means a prescription or equivalent authorization or approval that (in accordance with Section 1.03 of the
Agreement to which this Schedule "A" is attached (the "Agreement")) is a Selected Country equivalent of My Prescription (defined below);
and
(b) "Personal Information" means personal health and medical information about me (including, without limitation, my medical history
and drug history), my contact and demographic information (including, without limitation, my full name, address and phone number) and
payment information.
1.4 Without limiting anything else herein, I hereby provide my consent to allow a physician retained by You!Drugstore or My Agents as my
agents and attorneys on my behalf (an "Agent Physician"), in each Selected Country where My Medications are being purchased, to
obtain Personal Information and other necessary documentation from My Doctor. This Agent Physician will be a duly licensed physician in
the Selected Country where I am purchasing My Medications. For example, if My Medications are being purchased only in Canada, this
Agent Physician will be a licensed Canadian physician; if they are being purchased in more than one Selected Country, an Agent Physician
will be engaged in each Selected Country in which My Medications are being purchased (if required by the laws of that Selected Country in
order for My Prescription to be filled), in connection with those of My Medications that I am purchasing in that Selected Country.
1.5 I further consent to You!Drugstore and each Agent Physician, each Dispensing Pharmacy and My Doctor being able to contact one
another to discuss my Personal Information, as it pertains to the prescribing and dispensing of My Medications. I understand that the rea-
son for this consent is to provide each Agent Physician and each Dispensing Pharmacy with the full opportunity to conduct an independent
analysis of whether My Prescription is appropriate, and discuss any potential medical complications that might arise. My Personal Informa-
tion and information concerning My Prescription will also be provided to You! Health Services Limited Partnership, on whose behalf You!
Drugstore carries out its marketing and administrative services, in order to facilitate the processing of My Order and to establish and main-
tain my customer account. I further understand that my Personal Information will not be used for any other reason, and will be kept in strict
confidence. I further confirm and acknowledge that I am under the ongoing care of My Doctor, and I agree to regularly visit My Doctor and
to promptly advise the Agent Physician and You!Drugstore of any changes to my medical condition or prescriptions. It is clearly understood
that I am not seeking medical treatment or service of any kind from any Agent Physician, You!Drugstore or My Agents with regard to any
medical advice, professional advice or treatment of any kind whatsoever. I have relied only on My Doctor in respect of My Prescription.
1.6 I hereby specifically acknowledge that I am aware that You!Drugstore will be transmitting my Personal Information by electronic means
(for example fax, or secure internet) to My Agents. I understand that the use of electronic means will enhance the efficiency and timeliness
of processing My Order. I also understand that You!Drugstore, as a custodian of my Personal Information, will take precautions to protect
my Personal Information from improper disclosure or use. I hereby consent to You!Drugstore's transmission of my Personal Information by
electronic means to My Agents.
1.7 If I was directed to You!Drugstore's services through an intermediary (for example, a pharmacy benefit manager, health management
organization or other service provider, or a City or State or other group program), I hereby authorize You!Drugstore to release Personal
Information to such an intermediary if required for quality assurance or auditing purposes, or to permit the processing of any claims on my
behalf. It is my understanding that all such intermediaries will provide confidentiality covenants to You!Drugstore whereby they agree to
hold any such information in strictest confidence and to abide by the privacy policies of You!Drugstore relating to the protection of my Per-
sonal Information. I specifically consent to the transmission of the forgoing information to such intermediaries by electronic means.
1.8 Subject specifically to Sections 1.04, 1.06, 1.07, and of the Agreement, I authorize and appoint You!Drugstore and My Agents as my
agents and attorneys for the purpose of taking all steps and signing all documents on my behalf necessary to package or re-package My
Medications and to arrange delivery of them to me, to the same extent as I could do if I were personally present taking those steps and
signing those documents myself.
1.9 I confirm, acknowledge and agree that I initiated a consultation with You!Drugstore and that You!Drugstore is not located in the United
PART 2 - DISCLOSURE AND REPRESENTATIONS
2.1 I hereby represent and confirm to You!Drugstore, and to each of its affiliates, associates, related companies, subsidiaries and parent
company and each of their respective directors, officers, shareholders, employees, contractors, subcontractors, successors and assigns
and to My Agents that:
(a) My Medications were prescribed by a doctor ("My Doctor") licensed to practice medicine in the country, state or other applicable
jurisdiction in which I reside, or where I sought treatment;
(b) the prescription for My Medications ("My Prescription") was lawfully obtained by me from My Doctor;
(c) I will use My Medications strictly according to the instructions provided by My Doctor, as the person for whom they were prescribed. I
will not allow anyone else to use My Medications;
(d) I can make my own medical decisions according to the laws of the place where I reside;
(e) My Prescription has not been altered in any way, nor has it been filled prior to submission to You!Drugstore. I agree to immediately
destroy all copies of My Prescription once it has been filled;
(f) I am not seeking or relying on any medical information, advice or approval from You!Drugstore or My Agents, and I have consulted a
qualified physician licensed in the jurisdiction where I obtained My Prescription within the last year;
(g) I will immediately contact My Doctor in the event I suffer any unexpected side effects from any of My Medications;
(h) I understand that it is my responsibility to have regular physical examinations by my primary licensed physician that is responsible for
my care, including all suggested testing, to ensure that I have no medical conditions or problems which would contraindicate me taking My
Medications; and
PART 3 - PURCHASE AND SALE TERMS
3.1 You Prescription Services Corp. will charge my credit card for the price of the medications and shipping charges as posted on
the youdrugstore.com web site on or about the day My Order is processed and all other documentation (including the Equivalent
Prescription) necessary to enable the Dispensing Pharmacy(ies) to fill My Prescription has been received. In the event my payment
is not authorized, You!Drugstore has the right to cancel My Order and attempt to provide me with notice of such cancellation.
3.2 I confirm, acknowledge and agree that:
(a) any of My Medications being purchased from a Dispensing Pharmacy will be packaged in child protective packaging if
dispensed in non-manufacturer produced packaging or if required by law in the jurisdiction of the Dispensing Pharmacy.
(b) if requested by me, the Dispensing Pharmacy(ies) may substitute a brand name prescription drug with a generic prescription
drug, where available, unless My Doctor indicates that there be "no substitution";
(c) Medications may be returned or exchanged within thirty (30) days of purchase. Should it be necessary to return or exchange
any product, I agree that I will contact You!Drugstore and will be given the address for the return depot. Any returned or exchanged
medications will be destroyed in accordance with applicable laws;
(d) You!Drugstore and My Agents reserve the right to refuse to assist me in obtaining My Order or any other order in their sole
discretion, in which event I will be entitled to a refund for monies paid for such order; and
(e) neither You!Drugstore nor My Agents provide their agency or attorney services as a substitute for healthcare or the advice of
my primary care physician.
3.3 I confirm, acknowledge and agree that to the extent that my customer account and patient records can be considered to be
owned by any person, same shall be owned by You! Health Services Limited Partnership.
3.4 I SPECIFICALLY CONFIRM, ACKNOWLEDGE AND AGREE THAT EACH AND EVERY ONE OF THESE TERMS AND
CONDITIONS (INCLUDING, WITHOUT LIMITATION, MY CHOICE OF SELECTED COUNTRY(IES) AND DISPENSING PHAR-
MACY(IES)) WILL AUTOMATICALLY, AND WITHOUT FURTHER ACTION BY ME OR You!Drugstore, APPLY TO AND GOV-
ERN ANY FUTURE ORDERS BY ME OF MEDICATIONS FROM You!Drugstore, UNLESS I SPECIFICALLY INDICATE OTHER-
WISE AT THE TIME OF ORDERING SUCH MEDICATIONS. WITHOUT LIMITING THE FOREGOING, EACH AUTHORIZATION
AND CONSENT PROVIDED BY ME IN THIS AGREEMENT WILL CONTINUE UNTIL I CANCEL SUCH AUTHORIZATION OR
CONSENT (WHICH I CAN DO AT ANY TIME).
3.5 BY PLACING MY ORDER WITH YOU!DRUGSTORE, I AM REPRESENTING AND WARRANTING TO YOU!DRUGSTORE
AND MY AGENTS THAT THE SALE, DELIVERY AND SHIPMENT OF MY MEDICATIONS AND/OR OTHER PRODUCTS
WHICH I REQUEST WILL NOT VIOLATE ANY IMPORT, EXPORT OR OTHER LAW OR REGULATION IN MY HOME JURIS-
DICTION AND/OR THE JURISDICTION TO WHICH MY MEDICATIONS AND/OR SUCH PRODUCTS ARE BEING SHIPPED.

Source: https://www.youdrugstore.com/patient_order_form_rev1.pdf