Online Pharmacy Direct
1915 Trade Center Way
Naples FL
USA 34109

Phone: 1-877-592-9192
Fax: 1-877-737-3517

Order Form

Affiliate/Group

Affiliate/Offer#

Broker:


Please enter the information
above if Applicable




Step 1:
Complete and sign the Order Form on the Signature lines at the bottom of Each page.

Step 2: Fax to Toll Free 1-877-737-3517
, along with your original Prescription and a copy of a Picture ID. Make sure your doctor�s DEA number, license and phone # is written on prescription. If you do not have your prescription, have your doctor or pharmacy fax it to us. If cannot fax, please mail to: Online Pharmacy Direct, Canada or Call us Toll Free 1-877-592-9192.

Medication including strength Please Print or Type Accurately (Maximum of 90 days supply of each medication can be shipped at any one time) Directions Qty. Generic Allowed (Y/N) # Refills
(No. or PRN)
         
         
         
         
         


PATIENT INFORMATION: (Please Print or Type Accurately) Please Check:
 
New Customer
 
Existing Customer
It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one:
 
YES
 
NO
Check One:
 
Send my medicine in Original Manufacturers Container, which may not be childproof
 
Send my medicine in vial, which is childproof & is not in original container

 

Name (For Pet medication(s) Please Enter the Owner's Info!): ________________________________________

Address: ___________________________________________________________________________________

City: ________________________ State: _________ Zip: ____________ Employer or a Group ____________

Tel # (Day): __________________________________ Tel # (Night) :_________________________________

Date of Birth: ______________________ Sex: _______ Weight: ________

How did you hear about us?_______________________________ E-mail: ______________________________

Do you have any allergies (including drug allergies)? _____ If Yes please list: ___________________________

Please list all medications you are currently taking here: ____________________________________________

___________________________________________________________________________________________


Please Circle Any Medical Conditions that apply to you: Blood Disorders, Cancer, Immune disorders, Poor wound Healing, Neurological disorders, Diabetes, thyroid, or other endocrine disorders, Nutritional deficiency, Lipid or cholesterol disorder, Heart disease, Renal or kidney disease, Liver Disease, Orthopedic or Muscle disorders, Emotional disorders, Glaucoma.

If you circled any of above, please elaborate here:

__________________________________________________________________________________________

PRESCRIBING PHYSICIAN INFORMATION:   Name: _____________________________________________

Address: ________________________________________________________ DEA#: ____________________

City: _______________________________________ State: _______ Zip: ___________ Tel: ______________


CREDIT CARD BILLING INFORMATION:

Credit Card # ____________________________ Exp. Date: __________ Cardholder's Tel: _______________
( MasterCard Only)

Cardholder's Address: ________________________________________________________________________


________________________ _______________________ __________
CARDHOLDER'S NAME (print name) CARDHOLDER'S SIGNATURE DATE

 

 

PATIENT AGREEMENT

BY SIGNING BELOW I CONFIRM THAT:

  1. IF PLACING THIS ORDER AS A CUSTOMER, I, ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS AND SUCCESSORS, HEREBY AGREE TO ALL OF THE FOLLOWING TERMS AND CONDITIONS, REPRESENT THAT I UNDERSTAND ALL OF THE FOLLOWING TERMS AND CONDITIONS AND THAT I HAVE HAD ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.

  2. IF I AM PLACING THE ORDER ON BEHALF OF SOMEONE ELSE, I REPRESENT THAT I HAVE ALL NECESSARY CONSENT, PERMISSION AND AUTHORIZATION TO DO SO ON BEHALF OF THAT PERSON AND THEIR HEIRS, ASSIGNS AND SUCCESSORS AND THE PERSON I REPRESENT AGREES TO ALL OF THE FOLLOWING TERMS AND CONDITIONS, UNDERSTANDS ALL OF THE FOLLOWING TERMS AND CONDITIONS AND HAS HAD AN ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.

AUTHORIZATION AND CONSENT
I hereby appoint Global Care, Ltd. (GLC) and its partnered Canadian Pharmacy (�Pharmacy) as my agent and attorney for the purposes of obtaining a prescription from a Medical Doctor in Canada (the "Canadian MD") which corresponds to the prescription included in this order, which may include directly contacting my prescribing physician, and purchasing and arranging delivery of the medications prescribed in the Canadian prescription, substantially on the terms set forth below, all to the same extent I could if I personally took such steps. I hereby consent to GLC, the Canadian MD and any Pharmacy supplying my order, collecting my personal and medical information, maintaining the information necessary to quickly process future orders which may include retaining on file my name, address, phone number, payment and other information and verifying future orders. I confirm that my personal information will be handled only GLC�s order-processing employees and contractors (including physicians and nurses, pharmacists and pharmacy technicians) according to the Privacy Policy as posted on GLC website which may be updated from time to time.

DISCLOSURE AND REPRESENTATIONS
I represent that all of the following statements are true and agree GLC and its contractors (physicians and nurses, pharmacists and pharmacy technicians) are relying on these representations:

  1. I am of the age of majority or older where I reside;
  2. I can make my own medical decisions according to the law of the place I reside;
  3. The prescription I am requesting GLC to assist me in obtaining was prescribed by a qualified physician licensed where I obtained the prescription;
  4. The prescription I am requesting GLC to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to GLC. I agree to immediately destroy all copies of my prescription once it has been filled;
  5. I am not violating any laws where I reside by placing this order;
  6. I will use any medication obtained for me by GLC strictly according to the instructions provided by the physician who prescribed the medication;
  7. I am placing this order for medication for my sole use and I will not provide any quantity of this medication to any other person;
  8. I am not seeking or relying on any medical information from GLC and I have consulted a qualified physician licensed where I obtained the prescription within the last year; and
  9. I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me GLC. GLC has made no representations or warranties to me, including, without limitation, representations or warranties with respect to any delivered medications' usefulness or fitness for a particular purpose (including, without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown).

PURCHASE AND SALE TERMS
Pharmacy will charge my credit card the following amounts: the medication price (in U.S. dollars) and shipping fee as posted on the GLC�s Website on the day GLC receives my order. In the event my payment is not authorized, GLC has the right to cancel my order and attempt to provide me with notice of such cancellation. GLC reserves the right to refuse to assist me in obtaining any order in its sole discretion, in which event I will be entitled to a refund for monies paid for such order. GLC does not provide its agent or attorney services as a substitute for health care or the advice of a physician. GLC will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the supplying pharmacy does not correspond with my prescription. Pharmacy will charge the customer's credit card or withhold money from any refund due to the customer in an amount equal to GLC's shipping charge and a 15% restocking fee for all unauthorized returns or for any packages returned due to customer's refusal of shipment. The 15% restocking fee is calculated on the cost of the order not including shipping. All prices quoted on the web site are subject to change without notice. GLC will not honor any typographical errors concerning price, strength, dosage, or any other information concerning the quoted medication(s).

RELEASE AND WAIVER
I hereby release and discharges GLC and its employees, officers, agents, representatives and contractors (including physicians and nurses, pharmacists and pharmacy technicians) harmless from any and all suits, demands, liabilities, claims, actions, expenses, losses and damages of any kind or nature whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation (including reasonable attorney fees) arising from:

  1. My use of the medication obtained for me by GLC including, without limitation, any and all side effects whether previously known or unknown;
  2. GLC's or its contractors' manner or timeliness of completing any actions I have authorized above, including, without limitation, their manner or timeliness in prescribing the appropriate strength, dosage, or dispensing generic drugs and non-child-protective packaging; and
  3. My breach of any terms, conditions or representations or warranties in this agreement. Nothing in this release shall be deemed to release any Pharmacy or pharmacist contractors from compliance with the applicable standards of practice or usual professional duties and obligations, which a pharmacist owes.

GOVERNING LAW
This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of the province in which the Pharmacy is located. I have read and understood all of the foregoing terms and conditions.

 

________________________ _______________________ __________
PATIENT'S NAME (print name) PATIENT'S SIGNATURE DATE