The undersigned, (hereinafter the “Client”) confirms that:
 

1. The Client is of the age of majority in the jurisdiction in which the Client ordinarily resides (“Place of Residence”).
2. The Client is not restricted from making his or her own medical decisions under the laws of the Place of Residence of the Client.
3. The Client confirms to (Name) Pharmacy Inc. and (name) . (hereinafter “The Providers”) that the pharmaceutical's ordered by the Client (“the Ordered Product”) were prescribed by a duly qualified medical practitioner in the Place of Residence of the Client after a personal examination by the prescribing physician necessitating the need for the Ordered Product(s) for the Client’s specific diagnosed medical condition.
4. The Client has not violated any laws in the Place of Residence of the Client, in obtaining the prescription for the Ordered Product.
5. The Client confirms that the Ordered Product will not be used in any way whatsoever, except as prescribed by the duly qualified medical practitioner who originally issued the Prescription to the Client (“The Client’s Doctor”) and that the duty of care is the responsibility of the Client’s Doctor.
6. The Client confirms that no person other than the Client will use the Ordered Product.
7. The Client confirms that he or she did not seek or request a medical opinion of the (Country) licensed co-signing physician regarding the strength, dosage, usefulness or qualities of the Ordered Product or the duration of use, frequency of use, or appropriateness for their particular medical condition, nor do they seek any medical advise in any way from the (Country) co-signing physician.
8. The Client releases and discharges The Providers, and all of their officers and directors, agents, and employees from any and all liability, claims or causes of action with respect of the use or application of the Ordered Product by the Client, including, but not limited to undesired side effects.
9. The Client confirms the release in the preceding paragraph also benefits and protects any (Country) Physician retained by the Providers to lawfully issue the prescription in (Country)  as directed by the Client’s Doctor.
10. The Client agrees that child protective packaging may not be used by the Providers and the Client releases and discharges the Providers and all of their officers and directors, agents and employees from any and all causes of action with respect errors or omissions by the company or agency responsible for transporting the Ordered Product to the Client.
11. The Client grants Limited Power of Attorney to the Providers, for the limited purpose of signing any documents as required by the laws of the Province of state/province, Country, which are necessary to permit the delivery of the Ordered Product to the Client, in the same manner as the Client could, if the Client had personally attended at the Providers place of business in state/province, Country.
12. The Client accepts to the jurisdiction of state/province, Country and agrees that any dispute that arises between the Client and the Providers shall be heard by the courts in state/province, Country. The Provider and Client hereby submit to the jurisdiction of Manitoba and agree that any dispute shall be heard by the Courts in state/province, Country, including, but not limited to any claims of negligence and/or malpractice. Further, the Client agrees that the laws of state/province, Country  shall apply in such a proceeding, agrees to these provisions on the basis that the Client understands that he/she is actively doing business in state/province, Country pursuant to the laws, policies and privileges of Canadian law including but not limited to the laws of state/province, Country and that the Client is benefiting from such laws, policies and privileges by participating in this program.
13. The Client acknowledges that the Ordered Product may not be returned for a refund or an exchange.
    
    By signing this document the client confirms that he/she has read and understood these terms and that they are true and correct and the client agrees that the terms herein are binding on the client and the heirs assigns, successors and personal representatives of the client.