I understand I must read and agree to the following acknowledgment and release form before World Canadian Pharmacy and it's Associated Pharmacy will be able to fill any of my prescriptions. World Canadian Pharmacy and its Associated Pharmacy, its affiliates and related companies, shall be hereinafter collectively referred to as WCP&AP.

I hereby confirm that I am 21 years of age or older, or the parent or legal guardian of a patient if under the age of 21 years, and that I am fully competent to make my own health care decisions. I am aware of the potential side effects associated with prescription medications and understand that it would be a violation of law to falsify any information on my questionnaire or other medical record for the purposes of obtaining prescription medication. I agree to truthfully and to the best of my knowledge answer all the questions in my medical questionnaire. I agree that if I fail in any way to fully furnish my complete and accurate medical history if I become aware of any changes in my physical or medical condition in the future and I fail to notify WCP&AP of such failure, that I am solely responsible for any adverse effects that I may suffer from taking or continue to take such prescribed medications. I confirm to WCP&AP that 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 the undersigned resides, that the prescription(s) for the pharmaceuticals were lawfully obtained from that physician and that the pharmaceutical(s) will be used only as directed and only by the person for whom the pharmaceutical was prescribed.

WCP&AP is required to have a licensed Canadian Physician (the "Canadian Physician") review my medical information for the purposes of independently verifying whether the medications prescribed by My Own Physician are appropriate. By reviewing my medical information, the Canadian Physician is not rendering or providing any service or advice to me whatsoever. I understand that it is my responsibility to have My Own Physician conduct regular physical examination of me, including any and all suggested testing by My Own Physician to ensure that I have no medical problems which would constitute a contradiction to me taking medication prescribed for my by My Own Physician. I agree that should I suffer adverse effects while taking any prescription medications, that I will immediately contact My Own Physician and that in the event I come under care of another physician, I inform him or her of any and all medications that I have been prescribed. I acknowledge and agree that WCP&AP recommend regular physician examinations with My Own Physician whose care I am under and who initially prescribed my medications.

I hereby give permission to My Own Physician to release any and all medical information and data whatsoever which WCP&AP shall request for the purposes of performing a medical review to determine whether the medications prescribed by My Own Physician are appropriate in the circumstances. I hereby give permission to My Own Physician to release my medical files and medical reports as needed to obtain sufficient information for the purpose of such review.

I understand that any information provided to WCP&AP may be seen by its employees, agents and contractors and that this information will constitute a medical record. This information will not be shared with any associates or third parties outside of or not affiliated with WCP&AP. I understand and agree that WCP&AP are located in the country of Canada and that the Canadian Physicians and pharmacists working for WCP&AP are located and licensed to practice medicine and pharmacy, respectively in Canada only and any prescription if any that I am receiving from such physicians and pharmacists shall be deemed to be received by me in Canada. I further understand that WCP&AP will only verify and fill medications that My Own Physician has already prescribed to me. I also understand that no controlled medications, narcotics, tranquilizers or other medications that the Canadian Physician decides is inappropriate, will be filled.

I hereby waive any requirement of the Canadian Physician under the laws of Canada, the United States or any other country to conduct a physical examination.

I understand and agree that the review of medical information by a Canadian Physician is in no way intended as a means to diagnose any medical condition and does not substitute the requirement for me to obtain my own professional advice from My Own Physician. I will consult My Own Physician before taking any drug or changing my daily health regimen. I understand that any opinions, advice, statements, services, offers or other information expressed or made available by third parties (including merchants and licensors) are those of the respected authors of distributors of such content.

I hereby waive my right to pharmacy counseling, as I have previously been counseled.

I understand that World Canadian Pharmacy is a division of Spencer Media Group Inc., and release World Canadian Pharmacy and all associates, Spencer Media Group Inc. and all associates and directors, as well as all associated pharmacies and companies from all liability and error, and understand that ordering from World Canadian Pharmacy.com and its Associated Pharmacy is done so at my own risk.

I AGREE THAT WORLD CANADIAN PHARMACY, SPENCER MEDIA GROUP INC, ALL ASSOCIATES, DIRECTORS, ASSOCIATED COMPANIES AND PHARMACIES, AND THE CANADIAN PHYSICIAN SHALL NOT BE LIABLE FOR ANY LIABILITY, CLAIM, LOSS, DAMAGE OR EXPENSE OF ANY KIND OR NATURE CAUSED DIRECTLY OR INDIRECTLY BY ANY INADEQUACY, DEFICIENCY OR UNSUITABILITY OF THE PRESCRIPTION ISSUED BY THE CANADIAN PHYSICIAN OR THE INADEQUACY, DEFICIENCY OR UNSUITABILITY OF THE CANADIAN PHYSICIAN'S REVIEW OF MY MEDICAL INFORMATION. IN NO EVENT WILL WORLD CANADIAN PHARMACY, SPENCER MEDIA GROUP INC, ALL ASSOCIATES, DIRECTORS, ASSOCIATED COMPANIES AND PHARMACIES, AND THE CANADIAN PHYSICIAN BE LIABLE OR RESPONSIBLE FOR ANY DAMAGES WHATSOEVER, INCLUDING, DIRECT, INDIRECT, PUNITIVE, SPECIAL OR CONSEQUENTIAL DAMAGES, EVEN IF ADVISED OF THE POSSIBILITY THEREOF.

By using this site you agree to the terms and agreements between you and WCP&AP. This agreement also governs the use of our website worldcanadianpharmacy.com and all of its contents. You agree to be bound by this agreement each and every time you use this website and accept all responsibility for all charges if any associated with connecting to WCP&AP prescription service.

Return Policy: Due to the nature of the products, products are not returnable, all sales are final. Sorry no refunds. I understand that all prices will be charged to my credit card in US dollars.

I HAVE READ AND UNDERSTAND THE ABOVE REFERENCED PATIENT ACKNOWLEDGEMENT AND RELEASE FORM AND AGREE TO EACH OF THE FOREGOING TERMS.

Full Name _____________________________

Signature ______________________________ Date_______________