New Patient Mail / Fax Order Form

Fax to: 1-866-732-0306

Or mail to:

DoctorSolve Healthcare Solutions Inc.
Suite #2001, 7495 132nd Street
Surrey, B.C. Canada
V3W 1J8


Cover Sheet

Total Number of Pages (including this sheet)


Your Name: (as written on prescription)

1. Complete & sign the attached form

2. Fax toll-free 1-866-732-0306 (or mail) along with a copy of your original Prescription and a copy of a Picture ID or 2 of the following: birth certificate, passport, voter's card, marriage certificate, or military ID.

** Please note: if you order your prescriptions by mail, there is a $9.95 USD shipping fee ($15.95 USD for cold-pack items) per patient for an unlimited number of prescriptions. All prescriptions will be authorized for a 1-year period if indicated by the physician and will be honoured from the date on the prescription form. Medication shortages happen from time to time. If you have ordered a medication that is on shortage you will be notified prior to shipping. All prescription drug prices include pharmacy dispensing fee.


Please Attach Prescription to the Box Below Before Faxing:

Attach Prescription Here



 

Cart Details
Rx-= Prescription Required      Rx-= No Prescription Required
Medication 1   Qty  
Medication 2   Qty  
Medication 3   Qty  
Medication 4   Qty  
Medication 5   Qty  
Medication 6   Qty  
Medication 7   Qty  
Medication 8   Qty  
Medication 9   Qty  
Medication 10   Qty  

Billing Address
First Name:  
Last Name:  
Address:  
 
City / Town:  
State / Providence:  
Zip / Postal Code:  
Email:  

 

Shipping Address
First Name:  
Last Name:  
Address:  
 
City / Town:  
State / Providence:  
Zip / Postal Code:  
Email:  

 

Payment Method
For added security, a customer service specialist will call to collect credit card information. We proudly accept:
    

New Patient Questionnaire

If you have previously purchased from Doctor Solve Healthcare Solutions, you do not need to fill out the patient questionnaire below.

personal Information  
Last Name:  
First Name:  
Sex (M/F):  
Date Of Birth:  
Telephone:  
Alt. Telephone:  
Best Time To Call:  
Address:  
City:  
State / Provence:  
Zip:  

 

Physician Information  
Last Name:  
First Name:  
Phone:  
Fax:  
Address:  
City / Town:  
State / Providence:  
Zip:  

 

Medical History  
Drug Allergies:  
Major Operations:  
  
Preventative Health: Diabetes:
Mammogram
Pap
Prostate Check		 Type 1
Type 2
Diet controlled
Insulin
A1C
Other:
 Other:
Eye: Thyroid:
Glaucoma
Macular degeneration
Cataract
Ocular Pressures 		Hormone therapy
TSH
HRT
Other:
 Other:
Respiratory: Mood Disorder:
Asthma
COPD
Emphysema
Allergies 		Depression
Anxiety
Psychosis
Insomnia
Other:
 Other:
Cardiovascular: Musculoskeletal:
High blood pressure
Angina
Heart failure
Heart attack
Arrythmias
Heart surgery
PT 		Osteoporosis
Arthritis
Back pain
Autoimmune fibromyalgia
Other:
 Other:
Cholesterol: Cancer:
Stable
Unstable
Diet Controlled
LFT
Other:
 Other:
GI: Neurological:
GERD
Hiatus Hernia
Ulcer
IBS
Colitis
Liver 		Migraine
TIA
CVA
Neuropathy
Parkinson
Dementia
Seizures
Other:
 Other:
Bladder & Kidney: Dermatology:
Prostate
 Fungal Infection
Psoriasis
Rosacea
Other:
 Other:

 
Other Conditions/Comments:

 
 
 
 
 

 

Current Medication
Drug Name / Strength Instructions
(eg. 1/day)		 Time Used
(eg. 5 years)		 Medical Condition
(eg. high cholesterol)
       
       
       
       
       
       
       
       
       
       

 

Terms of Agreement
No prescription(s) will be filled until a signed and dated copy of this document and a completed Patient Profile have been received by Doctorsolve Healthcare Solutions Inc. These documents can be sent by fax to 1-866-732-0306 or mailed to Doctorsolve Healthcare Solutions Inc. Suite #2001, 7495 132nd St., Surrey, BC V3W 1J8

CUSTOMER AGREEMENT (Part A)

DoctorSolve (as defined below) has established relationships with licensed pharmacies in Canada and licensed pharmacies around the world, which have licensing requirements that are comparable to the ones in Canada. DoctorSolve will select the appropriate pharmacy to fill your prescription(s) based on product quality, availability and price.

If you only want your prescription filled by a licensed Canadian pharmacy, please check this box. □

I, as the undersigned, being over the age of 21, hereby:

Disclosure and Representations

Represent and confirm to DoctorSolve, its affiliates, related companies, and subsidiaries (hereinafter collectively referred to as “DoctorSolve” or the “DoctorSolve Agents”) that:
1. The pharmaceutical(s) to be delivered to me were prescribed by a doctor licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside or where I sought treatment.
2. The prescription(s) for the pharmaceutical(s) were lawfully obtained from that physician.
3. I will use any medication obtained for me by DoctorSolve strictly according to the instructions provided by the physician who prescribed the medication.
4. The pharmaceutical(s) will only be used as directed and only by the person for whom the pharmaceutical(s) were prescribed.
5. I can make my own medical decisions according to the law of the place where I reside.
6. The prescription(s) I am requesting DoctorSolve to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to DoctorSolve.
7. I am not seeking or relying on any medical information from DoctorSolve and I have consulted a qualified physician licensed where I obtained the prescription within the last year.
8. I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me by DoctorSolve.
9. I understand that it is my responsibility to have regular physical examinations by my primary US licensed physician that is responsible for my care including all suggested testing to ensure that I have no medical problems which would constitute a contraindication to me taking the medications being prescribed.
10. I acknowledge that DoctorSolve’s employees and agents have relied on the information and documentation that I am providing (including the Medical and Medication information) and I represent and confirm that I have fully disclosed all pertinent information and documentation to DoctorSolve. I agree to notify DoctorSolve of any changes to my physical or medical condition by providing an updated patient profile.

Authorization and Consent

11. I hereby authorize and appoint DoctorSolve as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf, necessary to obtain a prescription in Canada or elsewhere in the world, which is the equivalent of the prescription that I sent to DoctorSolve (the “Equivalent Prescription”) to the same extent that I could do personally if I were present taking those steps and signing those documents myself. This authorization shall include, but not be limited to, collecting personal health information about me, collecting similar information from my prescribing physician or pharmacist, and disclosing that personal health information to DoctorSolve employees, agents, affiliates and service providers including without limitation, the physician licensed in Canada or elsewhere in the world and any pharmacy or pharmacist being retained by DoctorSolve on my behalf, as required for the limited purpose of obtaining the Equivalent Prescription and filling my Order.
12. I hereby specifically acknowledge that I am aware that DoctorSolve will be transmitting my personal health information by electronic means (for example: fax and secure Internet) to its employees, agents, affiliates and service providers including the Canadian or global physician retained on my behalf. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that DoctorSolve, as a custodian of my personal health information, will take all appropriate precautions to protect my personal health information from improper disclosure or use. I hereby consent to DoctorSolve’s transmission of my personal health information by electronic means.
13. If I was directed to DoctorSolve’s services through an affiliate or intermediary (for example: Pharmacy Benefit Manager, Health Management Organization, or other healthcare service provider), I hereby authorize DoctorSolve to release the following data to such an intermediary:

a. a numerical identifier indicating that I was a patient referred from that source;
b. financial information that will permit the processing of any claims on my behalf;

It is my understanding that all such intermediaries will enter into Confidentiality Agreements where they agree to abide by the privacy policies of DoctorSolve relating to the protection of my personal health information. I specifically consent to the transmission of the forgoing information by electronic means.
14. I hereby authorize and appoint DoctorSolve, as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to package or re-package the pharmaceutical(s) and to deliver them to me, to the same extent as I could do personally if I were present taking those steps and signing those documents myself.
15. I authorize and appoint DoctorSolve as my agent and my attorney for the purpose of taking all steps and signing all documents on my behalf necessary for shipping my prescribed pharmaceutical(s) to me as if I had shipped the prescribed pharmaceutical(s) to my own address.
16. I acknowledge and agree that I initiated a consultation with DoctorSolve and that neither DoctorSolve nor the DoctorSolve Agents are located in the United States. I also acknowledge that the DoctorSolve Agents contracted by DoctorSolve on my behalf are located in Canada or elsewhere in the world and that all professional services that I receive from the physicians and pharmacists licensed in Canada or elsewhere in the world, as the case may be, are being received in those jurisdictions.
17. I agree that DoctorSolve may release my personal health information to the person(s) listed as my “caregiver” in the patient information form.
18. I specifically acknowledge and agree that any and all agreements reached, or contracts formed throughout the course of my purchase of the Pharmaceutical(s) shall be deemed to be made:

a. in respect of any pharmaceuticals that were dispensed in Canada, in any province of Canada, and accordingly shall be governed by the laws of the appropriate province and the laws of Canada applicable to such contracts and agreements; and
b. in respect of any pharmaceuticals that are dispensed elsewhere in the world, according to the local laws applicable to such contracts and agreements.

19. I specifically acknowledge and agree that any dispute that arises between me and DoctorSolve or any of the DoctorSolve Agents shall:

a. insofar as such dispute relates to DoctorSolve or any of the DoctorSolve Agents located in Canada, be governed by the laws of the Province of British Columbia and the laws of Canada applicable to contracts formed in British Columbia, and that the courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such disputes; and
b. insofar as such dispute relates to any DoctorSolve Agents located elsewhere in the world, the dispute shall be governed by the local laws applicable to contracts formed in that jurisdiction and the courts of that jurisdiction shall have sole and exclusive authority over any such dispute.

Purchase and Sale Terms

20. DoctorSolve will charge my credit card for the following amounts:

a. The medication price plus shipping and handling as posted on the DoctorSolve website on the day DoctorSolve receives my order; and
b. In the event my payment is not authorized, DoctorSolve has the right to cancel my order and attempt to provide me with notice of such cancellation.

21. The pharmaceutical(s) will be packaged, as per my request in the Medication Order form.
22. DoctorSolve shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available, unless the physician has indicated that there be “no substitution” or “dispensed as written”. That once purchased and shipped, no pharmaceutical product may be returned or exchanged.
23. DoctorSolve reserves the right to refuse to assist me in obtaining any order in its sole discretion, in which event I will be entitled to a refund of monies paid for such order.
24. DoctorSolve does not provide its agency or attorney services as a substitute for healthcare of the advice of the customer’s primary care physician.
25. DoctorSolve will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the supplying pharmacy does not correspond with my prescription.
26. I specifically acknowledge and agree that each and every one of these terms and condition will automatically and without further action by me or DoctorSolve, apply to and govern any future orders by me of pharmaceutical(s) from DoctorSolve unless I specifically indicate otherwise at the time of ordering such pharmaceutical(s). Without limiting the foregoing, each authorization and consent provided by me in this Agreement shall continue until I revoke such authorization or consent (which I can do at any time).

 

I have read and understood the terms and conditions set out in the Agreement and agree, on behalf of myself, my heirs, successors,
administrators and assigns, to be bound by these terms and conditions.

 

Signed this ______ day of ________________________, 200

 

________________________________________  ________________________________________
Signature                                                                   (Print Name)

 

CUSTOMER AGREEMENT (Part B)

Consent and declaration from U.S. patient

I, ___________________________________________, provide my consent to allow a physician licensed in Canada or elsewhere in the world to obtain my medical history, drug history, contact information and other necessary documentation from my U.S. physician. In this context, I further consent to both the Canadian or international physician and my U.S. physician being able to contact one another to discuss my medical condition, as it pertains to the prescribing of the medication(s) in question. I understand that the reason for this
consent is to provide the Canadian or international physician with a full opportunity to conduct an independent analysis of whether the medication(s) prescribed by my U.S. physician is/are appropriate, and discuss any potential medical complications that may arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence. I further allow the Canadian or international physician to share the information with any Canadian or international pharmacists in the process of filling my prescriptions.

I further agree to regularly visit my U.S. physician(s) and to promptly advise the Canadian or international physician and DoctorSolve of any changes in my medical condition, allergies, or prescriptions.

 

______________________________________    _________________________
Patient’s Name (Please print)                                 Patient’s Signature

______________________________________
Date