Terms and Conditions Pharmacy Agreement
Name of Patient
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First Name
Middle Name
Last Name
Email
example@example.com
Date of Birth
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Month
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Employer Name
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Employer Name
Member ID (If you don't know put N/A)
Member ID
Terms and Conditions Agreement
TRUE NORTH MEDS INC is a pharmacy that specializes in providing distance care from a head office located in Winnipeg, Manitoba, Canada. For more information on terms and conditions, with respect to the sales and delivery of medication, please visit True North Meds Inc website at www.truenorthmeds.com. Additionally, the following regulations, terms and conditions govern all sales between TRUE NORTH MEDS INC, and the patient/member. The patient/member is of the age of majority and legally entitled to purchase and receive the medications requested of TRUE NORTH MEDS INC (“True North”) and its Partners or Agents and I. The patient/member wishes to purchase prescription drug medications from, and have their order filled by a duly licensed pharmacy and pharmacist in Manitoba, Canada. II. The patient/member is and remains under the continuous care of their duly licensed United States based Physician, Nurse Practitioner, and/or Physician Assistant. (Collectively “Provider”) They are in possession of a duly prescribed lawful prescription written by their Provider. The patient/member is not seeking medical advice or relying on medical information from True North or their agents. III. The patient/member consents to True North and True North’s duly licensed Canadian physician consultant being able to contact the patient/member’s Provider who issued the prescription, as it pertains to the appropriate prescribing and dispensing of their medications from a True North facility. The patient/member understands that the reason for this consent is to provide the Canadian physician consultant and the True North dispensing pharmacist with the opportunity to conduct an independent drug utilization review (DUR) to confirm the appropriateness of the prescription(s) in the clinical setting and resolve any safety or efficacy issues that may arise. IV The prescription has not been altered in any way and the patient/member is already consuming the medication which was duly prescribed by their US based Provider(s) and fulfilled from a US domestic pharmacy. V. The patient/member will immediately contact their Physician/Provider who prescribed their medication if they experience any unexpected adverse events or side effects from medications ordered from True North. VI. The patient/member understands that the medications are sold, dispensed, and delivered within the jurisdiction of where the dispensing pharmacy operates. In the case of TRUE NORTH, this jurisdiction is Winnipeg, Manitoba, Canada. The patient/member acknowledges that they are importing the medication (s) from Canada into the United States for their own personal use. VII. The patient/member agrees to use the medication ordered through True North, according to the instructions stated by their Physician / Provider who issued the prescription, in the patient/member’s personal jurisdiction. The patient/member will not allow anyone else to use her / his medication(s) received. VIII. The patient/member has fully and accurately disclosed their personal and health information and authorizes TRUE NORTH to collect and use the information for the processing and delivery of the orders placed by the patient. IX. The patient/member grants to TRUE NORTH a power of attorney to take all steps, sign all documents, and act on the patient's behalf for the purposes of obtaining an equivalent prescription recognized and valid within the dispensing pharmacy's jurisdiction. This would be the same steps that the patient/member would perform if they were present in their home pharmacy’s jurisdiction. This shall include but not be limited to collecting and using the patient/member’s personal and personal health information as is needed to process her/his order. This shall continue until the patient/member revokes permission, which can be done at any time. X. The patient/member adheres to the jurisdiction of the dispensing pharmacy's operations, in this case, Manitoba, Canada. All agreements reached or contracts formed (expressed or implied) will be governed by the laws of the Province of Manitoba, Canada. Any legal disputes arising from this agreement will be resolved according to Manitoba’s laws and interpreted by Manitoba’s courts. XI. The patient/member understands that they accept responsibility for shipping and receiving their medication. The patient/member accepts that there may be delays, such as the United States customs or postal service holding the package, and that True North has no control over unexpected delays. True North takes all necessary precautions to pack your items in a safe and reliable manner. The patient/member agrees that they are responsible for having someone sign and accept shipments that requires a signature on delivery. True North is not responsible for shipments that arrive where no one is available to sign for delivery. I HAVE READ AND UNDERSTOOD THESE TERMS AND CONDITIONS SET OUT ABOVE AND AGREE THAT THEY SHALL BE BINDING UPON ME AND MY ASSIGNS, HEIRS AND PERSONAL REPRESENTATIVES. OR I am the parent/legal guardian/power of attorney for the patient/member disclosed herein, am over the age of majority, and have full authority to sign for and provide the above representations to True North and/or the dispensing pharmacy on the patient/member’s behalf.
Patient Signature
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Patient Information
Patient Allergies
Patient Current Medications
Notes for Pharmacy
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