New Patient Registration

Patient Authorization Agreement

Universal Drugstore which includes its officers, directors, affiliates, representatives, agents, contractors and sub-contractors (collectively, "Universal Drugstore") is an international prescription referral service committed to helping ensure that I, the undersigned patient ("I" or "Me"), am able to obtain medication, products and /or services ("Product") from licensed pharmacies. This Patient Authorization Agreement ("Agreement") shall govern all sales of Product facilitated by Universal Drugstore between me and any of Universal Drugstore's authorized pharmacies located in Canada, the United Kingdom, India, Mauritius, Turkey, Vanuatu, USA, and elsewhere (collectively, the "Pharmacy"). I acknowledge and agree as follows:

1. I am the age of majority, am fully competent to make my own health care decisions and have obtained any prescription(s) for the Product in a lawful manner.
2. I must have been taking the prescribed medication for a minimum period of thirty (30) days immediately prior to the date that I submit my prescription to Universal Drugstore for filling.
3. I understand that it is my responsibility to have my prescribing physician ("My Own Physician") conduct regular physical examinations, including any and all suggested testing to ensure that I have no medical problems which would constitute a contraindication to me taking the Product. I certify that I have had a physical examination by My Own Physician within the last two (2) months from the date hereof.
4. I agree that if I suffer any adverse effects while taking any prescription medication that I will immediately contact My Own Physician and that in the event that I come under the care of another physician, I will inform him or her of any and all medications that I have been prescribed. I further acknowledge and agree that Universal Drugstore recommends regular physician examinations with My Own Physician whose care I am under and who initially prescribed my medications.
5. I agree and understand that it would be a violation of the law to falsify any information provided to Universal Drugstore, including, but not limited to, any information on the Universal Drugstore Order Form ("Order Form"). I agree to truthfully, and to the best of my knowledge, answer all of the questions on the Order Form. I further agree and understand that I will be solely responsible for any adverse effects that I may suffer from taking or continuing to take the Product in the event that I have failed to fully furnish my complete and accurate medical history and/or if I fail to notify My Own Physician and Universal Drugstore of any change in my physical or medical condition.
6. I further understand that Universal Drugstore will only verify and provide Product that My Own Physician has already prescribed to me. No new prescription medications will be provided by Universal Drugstore. I also understand that no controlled medications, narcotics, tranquilizers, or other medications that Universal Drugstore decides are inappropriate, will be provided.
7. I appoint Universal Drugstore to act as my agent and attorney in order to take all steps that it deems necessary to have the Product dispensed by the Pharmacy, to the same extent as I could do if I were personally present at the Pharmacy, including: (a) collecting personal health information about me; (b) disclosing that information to and having a licensed physician perform an independent medical review in order to obtain a valid prescription for the Product; and (c) packaging the Product and delivering it to me. I hereby waive any requirement of the physician to conduct a physical examination. This authorization may be revoked by me at any time and shall continue until such revocation has been provided to Universal Drugstore, in writing.
8. There will be no additional fees charged to me in the event that an independent medical review is required to obtain a valid prescription for the Product.
9. I initiated contact with and understand that Universal Drugstore is not located in the United States.
10. The Product is sold and dispensed by the Pharmacy in accordance with the laws of the jurisdiction in which the Pharmacy is located. Title to the Product passes from the Pharmacy to me when the Product leaves the Pharmacy. The Pharmacy delivers the medication to my agent in the IPS's jurisdiction. Typically this agent is a delivery service, in which case I give the Pharmacy or its agent authority to select the agent on my behalf.
11. Any and all physicians and/or pharmacists ("Providers") retained by Universal Drugstore in order to obtain the Product from the Pharmacy are located and licensed to practice in the jurisdiction in which they are located. Any treatment that I receive from the Providers shall be deemed to be received by me in the jurisdiction in which the Providers are located.
12. I understand and agree that the review of my medical information by a physician is in no way intended as a means to diagnose any medical condition and does not substitute the requirement for me to obtain my own professional medical advice from My Own Physician. I agree to a direct all questions to My Own Physician. I will consult My Own Physician before taking any new drug or changing my daily health regimen.
13. Any and all agreements reached or contracts formed and transactions undertaken with or involving the Pharmacy are and shall be deemed to be made in the jurisdiction of the Pharmacy and shall be governed by the laws of the jurisdiction of the Pharmacy applicable to such contracts, agreements and transactions(unless Universal Drugstore elects otherwise in its sole discretion) . The Courts of that jurisdiction shall have sole and exclusive jurisdiction over any dispute that may arise between me and the Pharmacy and I agree to attorn to the Courts of that jurisdiction for any and all such dispute or disputes (unless Universal Drugstore elects otherwise in its sole discretion).
14. Universal Drugstore may communicate with me via email or telephone to discuss my order or pending refill order for the Product.
15. Not all of the services or products shown on Universal Drugstore's website are available in all jurisdictions.
16. Your credit card company may charge you a foreign transaction fee at their discretion which is in addition to the amount charged by Universal Drugstore. Foreign transaction fees are charged by the customers' card issuer and not by Universal Drugstore.
17. I acknowledge that the terms and conditions as found in this Agreement are readily available to me on a 24-hour basis from Universal Drugstore's website and acknowledge having had every opportunity to obtain independent legal advice with respect to this Agreement.

I HAVE READ AND UNDERSTAND THE FORGOING TERMS AND I AGREE THAT THEY SHALL BE BINDING UPON ME AND MY HEIRS, ASSIGNS, SUCCESSORS AND PERSONAL REPRESENTATIVES.

OR

"I am the parent/legal guardian/power of attorney for the customer disclosed herein, am over the age of majority, and have full authority to sign for and provide the above representations to Universal Drugstore on the customer's behalf."