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By signing this waiver, I agree, to release liability
and hold blameless Drug Mart Canada (DMC) including all of their affiliates,
directors, officers, employees, agents, physicians, and pharmacists from all causes
of action, suits, penalties, liens, and judgements liabilities, obligations,
losses, actual or consequential damages, actual or threatened claims which
may arise at any time by reason of relating to, arising directly or
indirectly out of any matter whatsoever related to the prescribing or
dispensing of my prescription medications.
I further agree that should I become aware of
any changes in my physical and mental conditions, I will notify DMC of such
changes, and agree that I am solely responsible for any adverse effects from
continuing taking these prescribed medications.
I understand and acknowledge that medical
diagnosis, opinions and treatments differ among physicians, and that there is
no warranty that treatments may be beneficial to me. I further state that all questions I have
about my prescription medications, including prescription drug interactions
and their risks and complications have been answered.
I also state that I have had physical
examinations by the physician within the last twelve months. I understand that is it is my
responsibility to have regular physical examinations by the U.S. licensed
physician to ensure I have no medical problems which would constitute a
contradiction to me taking the medications being prescribed for me.
I also agree that should I suffer any adverse
effects while taking these prescribed medications that I will immediately
contact the U.S. licensed physician whose care I am under. Should I come under the care of another
physician, I will inform him or her of any and all medications I am taking
which have been prescribed.
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I hereby give my consent to DMC physicians to review my
medical questionnaire to determine if the medications I am currently
prescribed by my U.S. licensed physician are appropriate. If necessary, you may contact my physician
for more information for the purpose of filling my prescription.
I understand that any information provided may
be seen by the corporation’s employees and that said information will
constitute a confidential medical record.
I hereby consent to the use of said records for the purposes of
filling any and all prescriptions.
I acknowledge that the physicians and
pharmacists contracted by DMC are located and licensed to practice medicine
and pharmacy in Canada. I further
understand and acknowledge that the services rendered of said pharmacists and
physicians will be provided in and from Canada.
DMC reserves the right to change this
Disclaimer and medical consultation form at any time. I agree to read the Patient Disclaimer
form every time I place a new order and understand that I must complete a new
Patient Disclaimer form once every 12 months.
I hereby state that I am at least 18 years old
and am fully competent to make my own health care decisions. If the patient is under 18 years of age,
disclaimer must be signed by legal guardian.
I understand that it would be a violation of the law to falsify
information on my medical questionnaire for the purpose of obtaining
prescription medication. I agree to
truthfully and to the best of my knowledge answer all the questions on the
questionnaire.
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