The undersigned, (the “Customer”) hereby confirms as follows:
That the Customer is of the age of majority in the jurisdiction in which the Customer ordinarily resides (the “Place of Residence”).
That the Customer is not restricted from making his or her own medical decisions under the laws of the Place of Residence of the Customer.
That the pharmaceutical(s) ordered by the Customer (the “Ordered Product”) were prescribed by a licensed and duly qualified medical practitioner in the Place of Residence of the Customer (the “Customer’s Doctor”) for the Customer’s specific diagnosed medical condition after a personal examination of the Customer by the Customer’s Doctor (the “Prescription”).
That the Customer confirms that with respect to any of the Ordered Product which he or she now or hereinafter orders from the store, that he or she has been taking the Ordered Product for at least 30 days immediately prior to the date he or she submitted his or her order.
That the Customer has not violated any laws in the Place of Residence of the Customer, in obtaining the Prescription for the Ordered Product.
That the Ordered Product will not be used in any way whatsoever, except as prescribed by the Customer’s Doctor, who originally issued the Prescription to the Customer and that the duty of care is the responsibility of the Customer’s Doctor.
That no person other than the Customer will use the Ordered Product.
That customer does not rely on any information obtained from pillplaza.com and any of its employees and / or its affiliates in making my decision to order any of the medications requested.
That customer will have to immediately contact the physician who provided the prescription included with this order in the event of suffering any side effects from any medications that has been bought from pillplaza.com.
That customer is wholly responsible to have regular examinations with the primary physician to insure that the customer does not have any medical problems, which could constitute a contradiction in taking the medications that the customer has requested. The customer agrees to take the responsibility that if he sees more than one doctor to inform each of those doctors of all medications that customer is taking.
That the Customer hereby releases and hereby discharges the store, its affiliates, subsidiaries and parent company (collectively, the “Providers”) and all of their respective officers and directors, agents, and employees from any and all liability, claims or causes of action, expenses, losses and damages of any kind whatsoever, including without limitation, general direct, special, indirect and consequential damages, even if advised of the possibility thereof, with respect to the use or application of the Ordered Product by the Customer, including but not limited to, undesired side effects, whether previously known or unknown, all such risks being assumed by the Customer. Nothing in this Authorization & Release Form shall be deemed to release any pharmacy or pharmacist contractors from compliance with the applicable standards of practice or usual professional duties and obligations, which such pharmacy or pharmacy contractors may owe.
That customer agrees and acknowledges that these medications are being shipped from a foreign country and the customer understands that these medications have not been manufactured in the United States.
That customer understands that packaging laws are different in foreign countries than in the US and therefore it is his responsibility to check with the doctor for the proper procedures and the risks that could occur from the use of this medication. If there is any change in the health, it is the responsibility of the customer to notify the doctor and determine if he should continue use of this medication.
That the Customer agrees that child protective packaging may not be used by the Providers and the Customer 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 Customer.
Customer agrees to provide prescription by fax or email or mail or in lieu of such provision authorizes the store to provide one from its in-house doctors.
That the Customer authorizes and appoints pillplaza.com as the customer’s agent and attorney for the purpose of signing all documents on my behalf necessary for shipping my medication to my own address as if the customer had been present to do so.
That customer authorizes and appoints pillplaza.com as the customer’s agent and attorney for the purpose of packaging or repackaging the medications in order to have them delivered to the customer as if the customer were personally present to take such steps.
That customer agrees that all agreements and contracts made between the customer, pillplaza.com and /or its affiliates shall be deemed to have been made in the City of Chennai, India and accordingly shall be governed by the laws of India.
That customer agrees that if any dispute arises between pillplaza.com and / or its affiliates and customer that the laws of India shall govern it and that the courts of India shall have sole and exclusive jurisdiction over any such dispute.
That the Customer agrees that neither the Providers nor any of their servants or agents or contractors, including the Indian Physician and the Indian Pharmacist, has made any representations to him or her, including without limitation, representations or warranties with respect to any delivered Ordered Product’s usefulness or fitness for a particular purpose (including, without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease or its potential or actual side or adverse side effects whether previously known or unknown.
That the Customer acknowledges that the Providers and their employees and agents and contractors, including the Indian Physician(s) and Indian Pharmacist(s) have relied upon the information, the documentation and the prescription(s) that the Customer is providing in this New Customer Order Form (including a completed Medical Questionnaire) and the Customer represents and confirms that he or she has and will fully disclose(d) all patient information and documentation to the Providers. The Customer understands he or she needs and agrees to notify the Providers of any change to his or her physical medical condition by providing an updated Medical Questionnaire.
THAT THE CUSTOMER HAS BEEN ADVISED BY THE PROVIDERS TO SEEK THE ADVICE OF LEGAL COUNSEL BEFORE SIGNING THIS AUTHORIZATION & RELEASE FORM.
That the Customer acknowledges that the Ordered Product may not be returned for a refund or an exchange.