For Internal Use Only

 

 

Data Entry
Allergy PHN
Fill RX
RX History
Verified
         
Check DIN
Check Pharm
Pack
Counsel
 
         
 

STEP 1: Print and sign the Order & Waiver forms below.

STEP 2: Fax completed forms along with a copy of your ORIGINAL PRESCRIPTION to Toll Free Fax 1-866-260-7981. If sending by mail, please send to:

Super Save Rx
#9 31205 Maclure Road
Abbotsford BC Canada V2T 5E5
Toll Free Phone 1-866-260-7980
email: info@supersaverx.com

STEP 3: Your prescription will be reviewed by a licensed Canadian physician and verified via phone with your doctor. NOTE: Canadian pharmacies cannot dispense drugs to patients without a valid prescription. Please allow approximately 10-14 business days from the time we receive your order to final delivery, to account for order processing, verification, and delivery time.

A) PATIENT INFORMATION

First Name:
 

Last Name:

         
Address:
         
City:
 
State:
         
Country:
 
Zip:
         
Telephone:
 
Alternate Telephone:
         
Fax:
 
Email:
         
Birth date:
(dd/mm/yy)
 
Gender:

B) PRIMARY PHYSICIAN INFORMATION

First Name:
 
Last Name:
         
Address:
         
City:
 
State:
         
Country:
 
Zip:
         
Telephone:
 
Fax:

C) SECONDARY PHYSICIAN INFORMATION

First Name:
 
Last Name:
         
Address:
         
City:
 
State:
         
Country:
 
Zip:
         
Telephone:
 
Fax:

C) PAYMENT INFORMATION (VISA or MasterCard #)

   
Card Holder Name
   
Credit Card #
         
Expiry Date (mm/yy):
     
         
Credit Card Verification Number
     
         
Example
 

 

Concent & Waiver of Liability

THE UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY:

1. Represents and confirms SuperSaveRx, along with its subsidiaries and affiliates (herein collectively “Super Save ”) that the pharmaceutical(s) to be delivered to the undersigned were prescribed by a doctor licensed to practice medicine in the country, state, or other applicable jurisdiction in which the undersigned resides, that the prescription(s) for the pharmaceutical(s) were lawfully obtained from that physician and that the pharmaceutical(s) will be used only as directed and only by the person for whom the pharmaceutical was prescribed.

2. Acknowledges that Super Save and Super Save’s employees and agents have relied on the information and documentation provided by the undersigned (including the Patient Questionnaire) and the undersigned represents and confirms that the undersigned has, to the best of his/her knowledge, fully disclosed all pertinent requested information and documentation to Super Save. The undersigned undertakes to notify Super Save of any changes to his/her physical or medical condition by providing an updated Patient Questionnaire.

3. Understands that it is the undersigned’s responsibility to have regular physical examinations by the licensed physician whose care he/she is under, including all suggested testing by said physician to ensure the undersigned has no medical problems, which would constitute a contradiction to him/her taking the medication(s) being prescribed.

4. Authorizes and appoints Super Save, as his/her agent and his/her attorney for the limited purposes of taking all steps and signing all documents on behalf of the undersigned necessary to obtain a prescription in Canada for the prescription sent by the undersigned to Super Save, to the same extent as the undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself, including, but not limited to, collecting personal health information regarding the undersigned directly from his/her prescribing physician or pharmacist and disclosing personal health information to Super Save employees, agents and service providers, as required, for the limited purposes set out above.

5. Authorizes and appoints Super Save as his/her agent and his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned necessary to package or repackage the pharmaceutical(s) and to deliver them to the undersigned, to the same extent as the undersigned could do if he/she were personally present taking those steps and signing those documents himself/herself.

6. Authorizes and appoints Super Save, as his/her agent and as his/her attorney for the purpose of taking all steps and signing all documents on behalf of the undersigned for shipping his/her prescribed pharmaceutical(s) to the undersigned as if the undersigned had shipped the prescribed pharmaceutical(s) to himself/herself to the undersigned’s address.

7. Understands and acknowledges that the pharmaceutical(s) will not be packaged in child protective packaging, unless requested by the undersigned on the Patient Questionnaire, and the undersigned releases and discharges Super Save and Super Save’s employees and agents, from any and all causes of action with respect to the late delivery, non-delivery or missed delivery of the pharmaceutical(s) sent to the undersigned.

8. Acknowledges and agrees that the undersigned initiated a consultation with Super Save and that Super Save is not located in the United States. The undersigned acknowledges that the pharmacists working for Super Save and the physicians contracted by Super Save on the undersigned’s behalf are located and licensed to practice medicine or pharmacy in Canada and that all treatment the undersigned is receiving from the said physician and pharmacist is being received in Canada.

9. Acknowledges and agrees that any and all agreements reached or contracts formed throughout the course of the relationship between the undersigned and Super Save shall be deemed to be made in British Columbia, and accordingly shall be governed by the laws of the Province of British Columbia and the laws of Canada as applicable to such contracts and agreements.

10. Agrees that any dispute that arises between him/her and Super Save, its affiliates, related companies, subsidiaries, parent company, officers, directors, employees or agents shall be governed by the laws of the Province of British Columbia and the laws of Canada applicable to contracts formed in British Columbia and the undersigned agrees that the Courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such dispute.

11. Understands that Super Save shall be entitled to substitute a prescription drug with a generic drug, where available in accordance with the British Columbia Drug Standards and Therapeutics Formulary, unless the physician has indicated that there be “no substitution”.

12. Acknowledges and understands that once purchased and shipped, no pharmaceutical product may be returned or exchanged.

13. Acknowledges and understands that a maximum of a 3 month supply of prescription medication can be shipped per person.

14. Acknowledges and understands that there is a flat rate shipping fee of $15 dollars U.S. charged on each order which covers up to $700 worth of goods(Members of the same household can combine orders).

 

Signatures of Consent

THE UNDERSIGNED HAS READ AND UNDERSTANDS THESE TERMS AND AGREES THAT THEY SHALL BE BINDING UPON THE UNDERSIGNED AND HIS/HER HEIRS, SUCCESSORS AND PERSONAL REPRESENTATIVES
Printed Name of Patient:
       
Signature of Patient
Date:
       
Signature of Credit Card Holder
Date:

 

Personal Medical History

             
 
Yes
No
   
Yes
No
1) Blood disorders *
  2) Cancer *
3) Immune disorders *
  4) Poor wound healing *
5) Neurological disorders *
  6) Diabetes, thyroid or other endocrine disorders *
7) Known nutrition deficiency including minerals or electrolytes *
  8) Lipid or cholesterol disorder *
9) Heart disease including atherosclerosis, angina, heart failure or history of heart attack *
  10) Renal or kidney
disease *
11) Liver disease *
  12) Drug Allergies *
13) Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome *
  14) Emotional disorders *
15) Surgery *
  16) Glaucoma *
17) Hyperlipidemia (high cholesterol) *
  18) Chemical dependency *
19) Upper respiratory disorders *
  20) Smoker *
21) Medications used in the last 12 months *
  22) Lung disorder (i.e., asthma, emphysema) *
23) Rheumatoid arthritis, lupus, or connective tissue diseases *
  24) High blood pressure *
25) Other illness not listed above *
   

 

(If answered yes to any of these questions, please explain further)

 

Allergies(please include drug allergies)

 

Prescription Details

*note we can only ship a 90 day supply according to FDA law
Medication
(example -. Liptior 20mg)
Directions
(example - Take one tablet
once per day)
Quantity Requested
(example - 100 tablets)
   
   
   
   
   
   
   
   
   
   

 

             
 
Yes
No
   
I would like the pharmacy to substitute generic drugs wherever possible to save me even more money.
   
 
* There is a flat rate shipping fee of $15 dollars U.S. charged on each order which covers up to $700 worth of goods( Members of the same household can combine orders).

 

   
attach prescription here