I (Full Name)   
Email address:   confirm the following information and provide the following release

By signing this Agreement below, I agree that:

1.         Under Canadian law, Norphar and its affiliated pharmacies cannot fill my prescription request a licensed Canadian physician (the "Canadian Physician") reviews my medical information and makes an independent judgment regarding the medications prescribed by my personal physician (“My Local Physician”).
2.         The  Canadian Physician is not rendering or providing any service or advice to me by reviewing my medical information. It is my responsibility to have My Local Physician conduct regular physical examinations of me, including testing suggested by My Local Physician, to ensure that I have no medical problems which would constitute a contraindication to my use of  medications prescribed by My Local Physician. If I suffer any adverse affects while taking any prescription medication, I will immediately contact My Local Physician.  If I come under the care of another physician, I will inform him or her of all medications that have been prescribed for me. I acknowledge that Norphar and it’s affiliated pharmacies recommends regular physician examinations with My Local Physician whose care I am under and who initially prescribed my medications.
3.         I hereby give permission to My Local Physician to release all medical information and data requested by Norphar for the purpose of reviewing my medical information. I understand that this will include reviewing my Patient Medical Information Form and any information submitted by My Local Physician.
4.         I understand that information provided to Norphar and it’s affiliated pharmacies may be seen by its employees, agents and contractors and that this information will constitute a medical record.
5.         I understand that Norphar and it’s affiliated pharmacies will only verify and prescribe medications that My Local Physician has already prescribed to me. The Canadian Physician cannot prescribe any additional medications.  I understand that the Canadian Physician will not approve any controlled medications, narcotics, tranquilizers, or other medications that he or she determines not to be appropriate.
6.         I waive any requirement that the Canadian Physician examine me physically.
7.         The  review of my medical information by the Canadian Physician is in no way intended as a means to diagnose any medical condition and is no substitute for obtaining my own professional medical advice from My Local Physician. I agree to a direct all medical questions to My Local Physician. I will consult My Local Physician before taking any new medication or changing my daily health regimen.  Any opinions, advice, statements, services, offers or other information expressed or made available by third parties (including merchants and licensors) are those of the respective authors or distributors.  
8.         I confirm that I am eighteen years of age or older and that I am competent to make my own health care decisions. I am aware of the potential side effects and problems associated with prescription medications and understand that I would be violating law if I falsify any information on my Patient Medical Information Form or other medical records for the purposes of obtaining prescription medication.
9.         I agree to answer all questions on Patient Medical Information Form truthfully and to the best of my knowledge. I agree that if I fail in any way to furnish my complete and accurate medical history, and do not correct such failure, I am solely responsible for any adverse effects that I may suffer from taking or continuing to take medications supplied by Norphar.  I agree that I will notify Norphar of any changes in my physical or medical condition, and if I fail to notify Norphar of such changes, I am solely responsible for any adverse effects that I may suffer from taking or continuing to take medications supplied by Norphar.
10.        I certify that I have had a physical examination by My Local Physician within the last 12 months.
11.        Norphar provides administrative and marketing services to Canadian pharmacies engaged in filling prescriptions for individuals residing in the United States. I acknowledge and agree that Norphar does not provide any clinical or dispensing services and that it has no liability with respect to the appropriateness, suitability, strength or dosages of the medications prescribed or dispensed to me, including without limitation, any dispensing errors or side effects or ill effects of any kind.
12.        Due to the nature of prescription medications and requirements of Canadian and U.S. law, medications are not returnable. All sales are final.
13.        I acknowledge and agree that I am not relying on Norphar with respect to the dispensing of prescribed medications other than to forward the prescription to the dispensing pharmacy. Any disputes regarding the dispensing, shipping or other matters relating to the prescription are exclusively between me and the Canadian pharmacy whose name and address appears on the prescription container.

I agree                    I disagree