Patient Agreement

Glacial Supplies operates as an online marketplace and advertising platform where
licensed pharmacies carry on business and display their products and services to
the public. As a condition of the sale of any product or service (the "Products") from
a pharmacy operating on Glacial Supplies (the "Pharmacy"), you (the "Patient")
authorize Glacial Supplies to collect and use your personal information, order
information, and/or payment information, and represent and warrant to the
Pharmacy that,
"I am over the age of majority, and:
1. I have fully and accurately disclosed my personal information and personal
health information and consent to its use by the Pharmacy. I have had a physical
examination by a physician within the last 12 months, and do not require a physical
examination.
2. I understand that all Products shall be sold & dispensed by a Pharmacy
operating within a unique international jurisdiction and in a manner consistent with
the laws of that jurisdiction.
3. I authorize and appoint the Pharmacy, as my attorney and agent, to take all
steps, sign all documents and to act on my behalf as if I were personally present
and acting myself for the limited purposes of (a) obtaining a valid prescription for
any prescription which I have sent the Pharmacy; and (b) packaging my
prescriptions and delivering them to me. This authorization shall include, but not be
limited to: collecting and using my personal and personal health information as
reasonably necessary for the fulfillment of my order, including disclosure to a
licensed physician if required for the issuance of a valid prescription in the
jurisdiction of the Pharmacy. This authorization may be revoked at any time and
shall continue until I revoke it.
4. I understand that the Pharmacy is legally incorporated and authorized by law
to carry on business in the jurisdiction of the Pharmacy, and that I am purchasing
medications that have been approved for sale in the jurisdiction of the Pharmacy.
Title to my medications passes from the Pharmacy to me in the jurisdiction of the
Pharmacy when my medications leave the Pharmacy. All agreements reached or
contracts formed with the Pharmacy shall be deemed to be made in the jurisdiction
of the Pharmacy, the laws of the jurisdiction of the Pharmacy shall govern all
transactions, and I attorn to the courts of the jurisdiction of the Pharmacy, which
shall have sole and exclusive jurisdiction over any dispute arising between me and
the Pharmacy, its affiliates, officers and directors.
5. Refrigerated medication policy
I understand that my medication will be shipped Air Mail with signature required in
order to receive the package.
I understand that medications are sent with a WarmMark sensor to notify me if a
medication has breached room temperature. If my medication has breached room
temperature, a pharmacist led investigation will commence. I understand that a
WarmMark doesn’t mean that a medication has been negatively affected.
I agree that prior to my first order being shipped, I will provide the following:
- A piece of photo ID
- A valid prescription
I understand that once the medication is dispensed and shipped from the
pharmacy, the medication is my own and that it is not possible to return
prescription medications. I understand that I am responsible for selecting the
appropriate shipping method based on the outdoor temperatures during the time in
which my package will be traveling. Although the risk is very low, I agree to assume
the risk if a medication is damaged in transit, seized by customs or spoils.
6. I have read and agree to the Terms of Sale and that they shall govern the
purchase of all products and services.
OR
"I am the parent/legal guardian/power of attorney for the Patient disclosed herein,
am over the age of majority, and have full authority to sign for and provide the
above representations to the Pharmacy on the Patient's behalf."
I HAVE READ AND UNDERSTAND THESE TERMS AND AGREE THAT THEY SHALL BE
BINDING UPON ME AND MY ASSIGNS, HEIRS AND PERSONAL REPRESENTATIVES."