Questionaire

PATIENT PROFILE
Enter your Contact Information and primary address: (Please Print Clearly)
* First Name:		Middle Name:
* Last Name:		* Gender:	Male Female
* Date Of Birth:	Day Month Year	* Weight (lbs):
* Primary Address:		* City/Town:
		* State:
* Zip Code:		* Country:
Email:
* Phone (Home):		Phone (Work):
Fax:		Phone (Cell):
Shipping Instructions:

Shipping Address (if different than the address above) NOTE: Your primary address (above), if this is the only address given, or your separately stated shipping address (below) will be used as the "ship to" address for your prescription orders. The address you provide will be used for all future orders unless and until you notifiy us that your shipping address has changed.
Shipping Address:		City/Town:
		State:
Zip Code:		Country:

Medical Information
Enter information about your Primary Physician:
* First Name:		* Last Name:
* Address:		* City/Town:
		* State:
* Zip Code:		* Country:
* Phone:		Fax:

Check all the medical conditions that you “currently”have:
Alzheimers Disease	Epilepsy	Liver disease
Anxiety	Glaucoma	Osteoporosis
Arthritis - Rheumatoid, Osteoarthritis & Lupus	Heart disease (please describe)	Parkinsons Disease
Asthma	High blood pressure	Schizophrenia
Cancer (please describe)	HIV / AIDS	Thyroid disorders
COPD - Bronchitis & Emphysema	Hysterectomy	Tobacco use (do you smoke?)
Depression	Kidney or renal disease	Diabetes (please describe)
High Cholesterol
Please use the space below to add additional comments regarding the medical conditions you have selected above and/or other medical conditions not listed.

Drug Allergies: Please indicate the drug group and circle the corresponding medication.
A.C.E. Inhibitors (Vasotec, Altace, Zestril, Accupril, Capoten)	Glucocorticoids (Prednisone, Cortisone, Dexamethasone)	Penicillins (Amoxil, Ledercillin VK, Ampicillin, Augmentum)
Beta Adrenergic Blocking Agents (Inderal, Tenormin, Sectral, Betapace	Histamine H2 Inhibitors (Zantac, Tagamet, Pepcid)	Proton Pump Inhibitors (Aciphex, Nexium, Protonix, Prilosec, Prevacid)
Calcium Channel Blocking Agents (Norvasc, Diltiazem, Verapamil, Plendil, Nifedipine)	HMG-COA Reductase Inhibitors (Lescol, Zocor, Pravachol, Lipitor, Mevacor)	Quinolones (Cipro, Noroxin, Levaquin)
Carbamazepine (Tegretol)	Hydantoins (Phenytoin, Dilantin)	Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Luvox, Celexa, Paxil)
Cephalosporins (Keflex, Ceclor, Cefzil, Ceftin)	Macrolides (Biaxin, Erythromycin, Zithromax)	Sulfonamides (Bactrim, Septra, Cotrim, Celebrex, Flomax, Glyburide, HCTZ)
Cox-2 Inhibitor (Vioxx, Celebrex, Bextra, Mobic)	NSAID's (Naprosyn, Aspirin, Relafen, Voltaren, Indocid, Motrin)	Tetracyclines (Tetracycline, Minocycline, Doxycycline)
Please use the space below to add additional comments regarding the allergies you have selected above and/or other allergies not listed.

Prescription Verification

Please list below any medications you are currently taking, how long you have been taking them and the conditions for which they have been prescribed: (*If applicable)

Medication (Length used and why)	Strength	Qty	Country	Price US$

NOTE: We will only send a 90-day supply in the original manufacturers package or less if requested AND available in original manufacturer's package.

** All sales are final. We cannot accept the return of any medications.
To minimize waiting time, please ask your physician to write the prescription for a 3-month supply plus 3 refills. Your initial order for each prescription will be delivered between 14 and 21 days in most cases. All refills should be delivered in approximately 10 days.

* Please use Generics to save more money:

Yes No

* Please use Childproof lids on containers:

Yes No

* How will you get the copy of the original Prescription to us?

I will fax the Prescription to you
I will send the original Prescription to the Pharmacy by mail
The Physician will fax the Prescription

Payment Options
We offer two forms of payment: Credit Card (Visa or Mastercard) and check. Please check which option you prefer and fill in the required information.
Option 1: CREDIT CARD		Option 2: PAY BY CHECK
* Card holder’s name:		* Account holder’s name:
* Credit Card Type:	Visa / MasterCard (circle one)	* Bank Account Number:
* Credit Card Number:		* Bank Routing Number:
* Expiration Month:		* Driver’s License Number Or Mother’s Maiden Name:
* Expiration Year:
* Cardholder's Signature:
Canadian Doctor Declaration I provide my consent to allow a physician licensed in Canada to obtain my medical history, drug history, contact information and other necessary documentation from my U.S. physician. In this context, I further consent to both the Canadian physician and my U.S. physician being able to contact one another to discuss my medical condition, as it pertains to the prescribing of the medication(s) in question. I understand that the reason for this consent is to provide the Canadian physician with a full opportunity to conduct an independent analysis of whether the medication(s) prescribed by my U.S. physician is appropriate, and discuss any potential medical complications that may arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence. I further agree to regularly visit my U.S. physician(s) and to promptly advise the Canadian physician of any changes to my medical condition or prescriptions.
Counselling Information We offer counselling to all of our patients about the prescription medications we provide. We also ensure that these consultations will be conducted in an atmosphere of confidentiality and privacy. A consultation is designed to provide you, our patient, with important information regarding your prescription medications. A consultation will cover the drug name, what the drug does, how and at what time the drug should be taken, drug interventions, the importance of taking the drug as directed (regularly or when needed), what to do if a dose is missed, common side effects, food, drink or other activities to avoid, special storage requirements and refill information. Would you like a pharmacist to contact you regarding any of these issues or any other drug related question? Yes____ No____
Attach a copy of your original prescription here!

questionnaire code:CRA-HW2004

* * * IMPORTANT * * *
We require that the full patient name, address (and telephone number) must be CLEARLY PRINTED on the written prescription in order for this prescription to be filled.

CANADARXASSIST.COM CUSTOMER AGREEMENT

(Version 2.4 effective June 3, 2004)

NO PRESCRIPTION(s) WILL BE FILLED UNTIL A SIGNED AND DATED COPY OF THIS DOUMENT AND A COMPLETED PATIENT PROFILE HAVE BEEN RECEIVED BY CANADARX (DEFINED BELOW)

Choose your dispensing pharmacy:

□

Option A - I want My Pharmaceuticals (defined below) to be dispensed either by a licensed Canadian pharmacy or by a licensed British pharmacy ( CanadaRx to choose based on availability and/or price advantages)

□

Option B - I want My Pharmaceuticals to be dispensed only by a licensed Canadian pharmacy

I, as the undersigned, being over the age of 21, hereby enter into this agreement (the “Agreement”) with CanadaRx (defined below), intending to be legally bound:

PART I - MY DISPENSING PHARMACY / MY PHARMACEUTICALS

1.01 I acknowledge and agree that if I have selected:

(a) Option A above, some or all of My Pharmaceuticals will be dispensed by (and I will be purchasing such pharmaceuticals from) a licensed British pharmacy (a “British Pharmacy”), selected for me by CanadaRx. CanadaRx will make the decision about which of My Pharmaceuticals will be dispensed by the British Pharmacy based on the availability or price of My Pharmaceuticals. Any of My Pharmaceuticals which are not dispensed by the British Pharmacy will be dispensed by a Canadian Pharmacy (defined below); and

(b) Option B above, My Pharmaceuticals will be dispensed by a licensed Canadian pharmacy (a “Canadian Pharmacy”).

1.02 Any of My Pharmaceuticals that are dispensed by a British Pharmacy will be shipped directly to me by the British Pharmacy, and any of My Pharmaceuticals that are dispensed by a Canadian Pharmacy will be shipped directly to me by the Canadian Pharmacy. If My Pharmaceuticals are being dispensed by both a British Pharmacy and a Canadian Pharmacy, they will be shipped separately but should arrive at approximately the same time.

PART II - DISCLOSURE AND REPRESENTATIONS

2.01 I hereby represent and confirm to CANADARX.COM, and to each of its affiliates, associates, related companies, subsidiaries and parent company and each of their respective directors, officers, shareholders, employees, contractors, successors and assigns (all of such persons are hereinafter collectively referred to as "CanadaRx") and to My Agents (defined below) that:

(a) I am delivering this Agreement to CanadaRx because I wish to place an order (“My Order”) with CanadaRx for certain pharmaceuticals, on the terms and conditions set out herein;

(b) the pharmaceuticals to be delivered to me in connection with My Order (“My Pharmaceuticals”) were prescribed by a doctor licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside or where I sought treatment;

(d) I will use My Pharmaceuticals strictly according to the instructions provided by the physician who prescribed the pharmaceuticals, as the person for whom such pharmaceutical(s) were prescribed;

(e) I can make my own medical decisions according to the laws of the place where I reside;

(f) My Prescription has not been altered in any way nor has it been filled prior to submission to CanadaRx. I agree to immediately destroy all copies of My Prescription once it has been filled;

(g) I am not seeking or relying on any medical information from CanadaRx or My Agents and I have consulted a qualified physician licensed in the jurisdiction where I obtained My Prescription within the last year;

(h) I will immediately contact the physician who provided My Prescription in the event I suffer any unexpected side effects from any of My Pharmaceuticals;

(i) I understand that it is my responsibility to have regular physical examinations by my primary US licensed physician that is responsible for my care including all suggested testing to ensure that I have no medical conditions or problems which would constitute a contraindication to me taking My Pharmaceuticals; and

(j) I acknowledge that CanadaRx and My Agents have relied and will continue to rely on the information and documentation that I am providing to CanadaRx (including My Order, My Prescription and the Patient Profile) and I represent and confirm that I have fully and accurately disclosed all pertinent information and documentation to CanadaRx. I agree to notify CanadaRx of any changes to my physical or medical condition by providing an updated Patient Profile.

PART III - AUTHORIZATION AND CONSENT

3.01 The authorizations and consents that I am providing herein to CanadaRx and My Agents commence on the date I sign this Agreement and will continue until I revoke them. I understand that I can revoke the consents and authorizations I have herein granted at any time.

3.02 I hereby authorize and appoint CanadaRx as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to obtain an Equivalent Prescription (defined below), to the same extent as I could do personally if I were present taking those steps and signing those documents myself. In this Agreement, the term “Equivalent Prescription” means a prescription that (in accordance with Section 1.01 above) is a British or a Canadian prescription, as the case may be, that is the equivalent of My Prescription. This authorization shall include, but not be limited to: collecting personal health information about me; collecting similar information from my prescribing physician or pharmacist; and disclosing that personal health information to CanadaRx employees, agents, affiliates and service providers, including without limitation any Agent Physician, any pharmacy and any pharmacist being retained by CanadaRx on my behalf (collectively, “My Agents”), as required, for the limited purpose of obtaining the Equivalent Prescription and filling My Order.

3.03 Without limiting anything else herein, I hereby provide my consent to allow a physician retained by CanadaRx on my behalf (an “Agent Physician”) to obtain my medical history, drug history, contact information and other necessary documentation from my US physician. This Agent Physician will be a licensed Canadian physician in respect of any of My Pharmaceuticals that are being dispensed by a Canadian Pharmacy, and will be a physician licensed in Britain in respect of any of My Pharmaceuticals that are being dispensed by a British Pharmacy. I further consent to both this Agent Physician and my US physician being able to contact one another to discuss my medical condition, as it pertains to the prescribing of My Pharmaceuticals. I understand that the reason for this consent is to provide this Agent Physician with the full opportunity to conduct an independent analysis of whether My Prescription is appropriate, and discuss any potential medical complications that might arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence. I further agree to regularly visit my US physician and to promptly advise the Agent Physician and CanadaRx of any changes to my medical condition or prescriptions.

3.04 I hereby specifically acknowledge that I am aware that CanadaRx will be transmitting my personal health 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 CanadaRx, as a custodian of my personal health information, will take all appropriate precautions to protect my personal health information from improper disclosure or use. I hereby consent to CanadaRx’s transmission of my personal health information by electronic means to My Agents.

3.05 If I was directed to CanadaRx’s services through an intermediary (for example Pharmacy Benefit Manager, Health Management Organization or other service provider), I hereby authorize CanadaRx to release the following data to such an intermediary: a numerical identifier indicating that I was referred from that source; and financial information that will permit the processing of any claims on my behalf. It is my understanding that all such intermediaries will provide confidentiality covenants to CanadaRx whereby they agree to hold any such information in strictest confidence and to abide by the privacy policies of CanadaRx relating to the protection of my personal health information. I specifically consent to the transmission of the forgoing information to such intermediaries by electronic means.

3.06 Subject specifically to Sections 1.01 above and 5.01 below, I authorize and appoint CanadaRx 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 Pharmaceuticals and to deliver them to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.

3.07 Subject specifically to Sections 1.01 above and 5.01 below, I authorize and appoint CanadaRx and My Agents as my agents and attorneys for the purpose of taking all steps and signing all documents on my behalf necessary for shipping My Pharmaceuticals to me as if I had done so myself.

3.08 I acknowledge and agree that I initiated a consultation with CanadaRx and that neither CanadaRx nor My Agents are located in the United States. I also acknowledge that My Agents contracted by CanadaRx on my behalf are located either in Canada or Britain and My Agents that are physicians or pharmacists are licensed to practice medicine or pharmacy in Canada or Britain, as the case may be, and that all services that I receive from CanadaRx and My Agents are being received (to the extent that My Pharmaceuticals are dispensed in Canada) in Canada or (to the extent that My Pharmaceuticals are dispensed in Britain) in Britain.

PART III - PURCHACE AND SALE TERMS

4.01 CanadaRx will charge my credit card the following amounts:

(a) the pharmaceuticals price and shipping charges (in Canadian dollars or US dollars, as determined by CanadaRx) as posted on the CanadaRx web site on the day CanadaRx receives My Order and all other documentation (including the Equivalent Prescription) necessary for CanadaRx to fill My Prescription; and

(b) in the event my payment is not authorized, CanadaRx has the right to cancel My Order and attempt to provide me with notice of such cancellation.

4.02 I acknowledge and agree that:

(a) My Pharmaceuticals will be packaged in child protected packaging, unless requested by me on the Patient Profile;

(b) CanadaRx and My Agents shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available, unless the physician has indicated that there be "no substitution";

(d) CanadaRx 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;

(e) neither CanadaRx nor My Agents provide their agency or attorney services as a substitute for healthcare or the advice of my primary care physician; and

(f) neither CanadaRx nor My Agents will exchange pharmaceuticals or return any monies paid once an order is filled, unless the pharmaceuticals provided to me by the supplying pharmacy does not correspond with my prescription.

4.03 I SPECIFICALLY ACKNOWLEDGE AND AGREE THAT EACH AND EVERY OF THESE TERMS AND CONDITIONS (INCLUDING, WITHOUT LIMITATION, MY CHOICE OF DISPENSING PHARMACY) WILL AUTOMATICALLY, AND WITHOUT FURTHER ACTION BY ME OR CANADARX, APPLY TO AND GOVERN ANY FUTURE ORDERS BY ME OF PHARMACEUTICALS FROM CANADARX UNLESS I SPECIFICALLY INDICATE OTHERWISE AT THE TIME OF ORDERING SUCH PHARMACEUTICALS. WITHOUT LIMITING THE FOREGOING, EACH AUTHORIZATION AND CONSENT PROVIDED BY ME IN THIS AGREEMENT WILL CONTINUE UNTIL I REVOKE SUCH AUTHORIZATION OR CONSENT (WHICH I CAN DO AT ANY TIME).

PART V - GOVERNING LAW / DISPUTES

5.01 I specifically acknowledge and agree that any and all agreements reached or contracts formed throughout the course of my purchase of My Pharmaceuticals shall be deemed to be made:

(a) in respect of any of My Pharmaceuticals that were dispensed in Canada, in the Province of Alberta, Canada and accordingly shall be governed by the laws of the Province of Alberta and the laws of Canada applicable to such contracts and agreements; and

(b) in respect of any of My Pharmaceuticals that were dispensed in Britain, in Britain and accordingly shall be governed by the laws of Britain applicable to such contracts and agreements.

5.02 I specifically acknowledge and agree that any dispute that arises between me and CanadaRx or any of My Agents shall:

(a) insofar as such dispute relates to CanadaRx or any of My Agents other than a British Pharmacy, be governed by the laws of the Province of Alberta and the laws of Canada applicable to contracts formed in Alberta, and I agree that the courts of the Province of Alberta shall have sole and exclusive jurisdiction over any such dispute; and

(b) insofar as such dispute relates to a British Pharmacy, be governed by the laws of Britain applicable to contracts formed in Britain, and I agree that the courts of Britain shall have sole and exclusive jurisdiction over any such dispute.

I HAVE READ AND UNDERSTOOD THE TERMS AND CONDITIONS SET OUT IN THIS AGREEMENT AND AGREE, ON BEHALF OF MYSELF, MY HEIRS, SUCCESSORS, ADMINISTRATORS AND ASSIGNS, TO BE BOUND BY THESE TERMS AND CONDITIONS.