207 - 1425 Marine Drive
West Vancouver, BC
Canada V7T 1B9
PH: 800-794-8552
Toll Free Fax: 866-868-2303
www.mapleleafmeds.com

WHAT'S NEXT?
1.	Each prescription is reviewed by a licensed and professionally registered physician.
2.	Prescriptions are filled by a licensed pharmacist and sent to your home
PATIENT CHECKLIST
I have completed patient information form I have signed the consent form I have been prescribed this medication by my doctor/physician My prescription(s) are less than 2 months old I am aware that it may take 3-4 weeks to receive my order
PLEASE NOTE Maple Leaf Meds facilitates the review of your prescriptions and your medical health by a licensed Canadian physician and forwards all prescriptions to an affiliated, certified licensed pharmacy to be filled. You can order to a maximum of a 3-month supply. If your prescription allows refills, you can simply call us to order your refill. We are not allowed to ship controlled substances such as amphetamines, benzodiazepines (e.g. Valium), or narcotics. Prescriptions are currently dispensed by the following certified pharmacy: Agar Pharmacy Ltd. 2400 Canoe Ave Coquitlam BC V3K 6C2 LIC: 13844
	Please feel free to call us Toll Free 1-800-794-8552 if you have any questions.

207 - 1425 Marine Drive West Vancouver, BC Canada V7T 1B9  PH: 800-794-8552 Toll Free Fax: 866-868-2303 www.mapleleafmeds.com

CUSTOMER INFORMATION

Name: ______________________________________________ Today’s Date:_______________

Phone Number:(____)______________Height:_________Weight:_________Gender:____M____F

Home Address:____________________________________________________Apt:___________

City: ___________________________ State: ___________________ZIP Code: ______________

Email:_________________________________

DOCTOR INFORMATION

Last Name:_____________________________ First Name: ___________________________

Address: ____________________________________________________________________

City: ______________________ State: _____________________ZIP Code: ______________

Telephone: (_________________) Fax: (__________________ )

Please Note: We do not usually ship medications in child-proof containers. If you require child-proof containers, please indicate by checking here _____ EZ-OPEN bottles _______

I understand that I am ordering from an international pharmacy and that once the pharmacy ships my medications, all sales are final. We are unable to take returns. I understand that prices are SUBJECT TO CHANGE without prior notice. When placing an order, please call to receive current pricing.

CUSTOMER HEALTH INFORMATION:

Date of Birth: ____________________

Known Drug Allergies (if none, indicate “None”):______________________________________

List every medication you are currently taking:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Please list any surgeries and/or misc. applicable health information
______________________________________________________________________
______________________________________________________________________

How did you hear about us?_________________________________________________________

Would you like a physician to call you? ____ Yes ____ No

Would you like a pharmacist to call you? ____ Yes ____ No

CREDIT CARD INFORMATION AND AUTHORIZATION

I, __________________ authorize Maple Leaf Meds to apply all applicable charges to my VISA or MASTERCARD credit card/debit card. There are NO OTHER FEES for shipping or filling my prescriptions in Canada.

207 - 1425 Marine Drive West Vancouver, BC Canada V7T 1B9  PH: 800-794-8552 Toll Free Fax: 866-868-2303 www.mapleleafmeds.com

Consent and Waiver of Liability Form

I ____________________ of the city of ________________ in the state of ___________ have read, understood and agree to the following:

I, __________________ am not seeking medical advice or treatment of any kind whatsoever in coming to Maple Leaf Meds and its physicians, employees, officers, agents and all others acting through or for it.

Neither Maple Leaf Meds, nor any of its physicians, employees, officers agents and all others acting through or for it, or anyone that is acting on its behalf, is providing medical advice, professional advice, treatment advice or treatment of any kind whatsoever to me.

I am coming to Maple Leaf Meds for the SOLE PURPOSE OF OBTAINING A PRESCRIPTION. I understand that no one on behalf of Maple Leaf Meds will take any steps whatsoever to determine whether the prescription is appropriate.

I _________________ hereby acknowledge that this prescription was originally prescribed by my American doctor whose name is __________________________ and that I will continue to have my medical condition and medications obtained in Canada monitored by my American in the United States of America.

I, ________________ have given the authority to Maple Leaf Meds to act as my agent and/or representative to facilitate the purchase of prescription medicine from a licensed Canadian pharmacist. We apply a $20.00 cancellation fee if you decide to cancel your order once it has been processed. Shipping of $9.99 per order (not per package). No minimum required!

In consideration of approving this prescription and in consideration of Maple Leaf Meds making this prescription, I agree not to sue Maple Leaf Meds, its physicians, employees, officers, agents and all others acting through or for it, and release Maple Leaf Meds, its physicians, employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription.

I hereby agree that the relationship between and the resolution of any and all disputes arising between me and Maple Leaf Meds, its physicians, employees, officers, agents and all others acting through or for it, shall be governed by and construed in accordance with the laws of the State of Washington, U.S.A.
I hereby acknowledge that the Courts of the State of Washington shall have jurisdiction to entertain any complaints, demands, claims or cause of action, whether based on alleged breach of contract or alleged negligence arising out of the signing of this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts of the State of Washington.

All of which is agreed.

FORM UPDATED: 09/21/2006