SpectrumPharmacy.com, Inc. - Prescription Medicines Online

Tel: (616) 977-3200 | Fax: (616) 956-0059 | Email: info@advancedhealthalliance.com

Patient Form

Patient Information

Physician Information

Full Name:
Date Of Birth:
Sex:	Male Female
Address:
City:
State:
Zip:
Work Phone:
Home Phone:
Fax:
Email:

Full Name:
Address:
City:
State:
Zip:
Phone:
DEA#:
License#:

Medical History

Approximate date of last medical appointment:
Reason:

Have you recently or are you presently taking ANY medicines or drugs?	Yes No
If Yes, Then details:

Are you allergic to any of the following? (if yes, please check)

AspirinCodeineAntibiotics – Penicillin, Sulfonamides, Other Other

If Other, Please explain:

Do you smoke?	Yes No
# per day:	# of years:

Do you have or have you had any of the following? (if yes, please check)

Chest Pain
Heart Attack
Shortness of Breath
Artificial Heart Valve
Swelling of Ankles
High/Low Blood Pressure
Heart Murmur
Heart Disease
Rheumatic Fever

Malignant Hypothermia
Tendency to Bruise
Prolonged Bleeding
Sinusitis
Asthma
Bronchitis
Tuberculosis
Cirrhosis
HIV Positive (AIDS)

Jaundice
Hepatitis A, B, C
Liver Disease
Recurring Kidney Infection
Kidney Stones
Food Intolerances
Ulcers
Diabetes
Thyroid Problems

Joint Replacement
Organ Transplants
Medical Implants
Epilepsy/Seizures
Drug/Alcohol Addiction
Cancer
Radiation Therapy
Other

If Other, please explain:

Women: Are you pregnant or think you might be?	Yes No
If Yes, Number of Months?:

Please list all surgeries/hospitalizations/serious illnesses and approximately when they occurred?

Is there anything else about your health that we should be aware of?

Release

The undersigned being over the age of 21 and mentally competent Confirm that the prescription(s) signed by my attending physician in the United States accurately represents the medications he/she wishes me to take and that I agree to take them as prescribed. I the undersigned have provided to the best of my knowledge and fully disclosed all pertinent requested information and documentation to the Pharmacy.

I release and discharge the Pharmacy and all of its employees and agents, including the doctors and pharmacists from any and all liability, claims or causes of action with respect to the appropriateness, suitability, strength or dosages of the medication(s) prescribed for the undersigned.

I authorize the Canadian doctor to co-sign this prescription(s) and the pharmacist to dispense the medication(s) specified therein solely for the purpose of enabling me to obtain these medications legally in Canada.

I also authorize the Canadian doctor to discuss or review my medical record with my attending physician if necessary.

I understand that both the Pharmacy and all of its employees and agents, including the doctors and pharmacists are in any way responsible for all adverse reactions to nor consequences arising from my taking these medications and I release them from any liability for events arising from my use of them

. I understand that the Pharmacy is not responsible for any delay in delivery of any pharmaceutical products due to unforeseeable circumstances such as customs, labor dispute or manufacturer’s supply problem. I release and discharge the Pharmacy and the Pharmacy employees and agents from any and all causes of action with respect to the late delivery, non-delivery, or missed delivery of the pharmaceuticals sent to me. It is my responsibility to ensure an uninterrupted supply of my medication.

I also understand and acknowledge that the pharmaceuticals may not be packaged in child protective packaging.

I agree that any dispute that arises between myself the undersigned, and the Pharmacy and all of its employees and agents, including the doctors and pharmacists shall be heard by the courts of Canada, that the courts of Canada shall have the sole and exclusive jurisdiction and that the laws in force in Ontario, Canada, shall apply to any and all disputes that may arise.

I acknowledge and understand that once purchased and shipped no pharmaceutical product may be returned or exchanged.

I understand this release must be signed and returned to the Pharmacy within 10 business days in order to continue receiving medications. Medication refills will not be shipped until This Pharmacy has a signed release on file.

Signature:_____________________________________ Date:__________________

Print Name:_____________________________________

Witness:_____________________________________ Date:__________________

Print Name:_____________________________________

07/02/2003

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