Please attach your prescription in this area

Affordable Rx
1515-One Lombard Place
Winnipeg MB R3B 0X3

Creating your Health Profile

Important
It is mandatory to have had a physical examination in the last 12 months to apply for a consultation. Have you had one?

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NOTE: Canada has one of the highest standards in the world for generic drug manufacturing and testing. Our rigorous approval system has ensured the highest quality drugs at the lowest prices for Canadians for many years. You too can enjoy the savings of our world-class generic drugs.

Patient Information: (Please Print Clearly)

*First Name: ________________ *Middle Name: ________________ *Last Name: ________________

*Your Weight: ____ lbs.   *Sex:  M / F                               *Birth Date: Day ___ Month ___ Year ___

Primary Address

*Street: ________________________ *City/Town: _________________ *State: _________________

*Zip Code: ___________________ *Country: _____________________

*Phone (Home): (      ) _________________ *Phone (Work): (      ) _________________

Fax: (      ) ___________________ Cell: (      ) ___________________ Email: ___________________

Alternate Address Location where you live for more than 3 months in each calendar year.

*Street: ________________________ *City/Town: _________________ *State: _________________

*Zip Code: ______________ *Country: __________________ *Phone (Home): (      ) ____________

Where would you like this order shipped?      Primary Address / Alternate Address

Please provide any other shipping information below. ________________________________________

Physician Information: (Please Print Clearly)

*First Name: ______________________ *Last Name: _______________________________________

*Street: ________________________ *City/Town: _________________ *State: _________________

*Zip Code: ___________________ *Country: _____________________

*Phone (Home): (      ) _________________ Fax: (      ) ___________________

Patient's Immediate Family Medical History

Patient Personal Medical History

Current Medications
Please list all medications you are currently taking and the condition for which they have been prescribed for:

Medications Ordered
NOTE: We will adjust quantities to meet manufacturers pack size when possible. If you require further space, please attach additional page(s).

AFFORDABLE RX - CUSTOMER AGREEMENT (Version 2.2 effective May 7, 2004)

NO PRESCRIPTION(S) WILL BE FILLED UNTIL A SIGNED AND DATED COPY OF THIS DOCUMENT AND A COMPLETED PATIENT PROFILE HAVE BEEN RECEIVED BY TAME HEALTH SYSTEMS (THS) DEFINED BELOW.

I, as the undersigned, being over the age of 21, hereby enter into this agreement (the "Agreement") with THS, intending to be legally bound:

PART 1 - DISPENSING PHARMACY(IES)

1.01     I acknowledge and agree:

1. on my order form I have selected, on a product by product basis, which country (the "Selected Country") I want to purchase My Pharmaceuticals from;
2. for each product I have ordered, THS will, as my agent, select a licensed pharmacy (the "Dispensing Pharmacy") from the Selected Country I want to purchase My Pharmaceuticals from;
3. the product(s) being dispensed by a Dispensing Pharmacy will be shipped directly to me by (and I am purchasing my pharmaceuticals from) the Dispensing Pharmacy;
4. it is only those of My Pharmaceuticals (defined below) that are being dispensed by a Canadian Pharmacy that I am purchasing from THS; and
5. if My Pharmaceuticals are being purchased from pharmacies in different countries countries, they will be shipped seperately but should arrive at approximately the same time

PART 2 - DISCLOSURE AND REPRESENTATIONS

2.01     I hereby represent and confirm to THS, and to each of its affiliates, associates, related companies, subsidiaries and parent company and each of their respective directors, officers, shareholders, employees, contractors, subcontractors, successors and assigns and to My Agents (defined below) that:

1. I am delivering this Agreement to THS because I wish to place an order ("My Order") for certain pharmaceuticals, on the terms and conditions set out herin;
2. the pharmaceuticals to be delivered to me in connection with My Order ("My Pharmaceuticals") were prescribed by a doctor ("My Doctor") licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside or where I sought treatment;
3. the prescription for My Pharmaceuticals ("My Prescription") was lawfully obtained by me from My Doctor;
4. I will use My Pharmaceuticals strictly according to the instructions provided by My Doctor, as the person for whom they were prescribed;
5. I can make my own medical decisions according to the laws of the place where I reside;
6. My prescription has not been altered in any way nor has it been filled prior to submission to THS I agree to immediatley destroy all copies of My Prescription once it has been filled;
7. I am not seeking or relying on any medical information, advice or approval from THS or My Agents and I have consulted a qualified physician licensed in the jurisdiction where I obtained My Prescription within the last year.
8. I will immediately contact My Doctor in the event I suffer any unexpected side effects from any of My Pharmaceuticals;
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 conditions or problems which would constitute a conrainidication to me taking My Pharmaceuticals; and
10. I acknowledge that THS and My Agents have relied and will continue to rely on information and documentation that I am providing to them (including My Order, My Prescription and the Patient Profile) and I represent and confirm that I have fully and accurately disclosed all pertinent information and documentation to THS. I agree to notify THS of any changes to my physical or medical condition by providing an updated Patient Profile

PART 3 - AUTHORIZATIONS AND CONSENT

3.01      The authorizations, powers of representation and consents that I am providing herein to THS and My Agents commence on the date I sign this Agreement and will continue until I revoke them. I understand that I can revoke the consents and autorizations I have herein granted at any time.

3.02      I hereby authorize and appoint THS and My Agents as my agents and attorneys for the limited purpose of taking all steps and signing al documents on my behalf necessary to obtain an Equivalent Prescription (defined below), to the same extent as I could do personally if I were present taking those steps and signing those documents myself. In this Agreement, the term "Equivalent Prescription" means a prescription that (in accordance with Section 1.01 above) collecting personal health information about me; collecting similar information from My Doctor or pharmacist; and disclosing that personal health information to THS employees, agents, contractors, subcontractors, affiliates and service providers, including without limitation any Agent Physician, any pharmacy and any pharmacist being engaged on my behalf (collectively, "My Agents"), as required, for the limited purposeof obtaining the Equivalent Prescription and My ORder being filled.

3.03     Without limitin anything else herein, I hereby provide my consent to allow a physician retained by THS on my behalf (an "Affiliate Physician") in each selected country where My Pharmaceuticals are being purchased from to obtain my medical history, drug history, contact information and other necessary documentation from My Doctor. This Agent Physician will be a duly licensed physician in the Selected Country where I am purchasing My Pharmaceuticals. For example, if My Pharmaceuticals are being purchased only in Canada, this Agent Physician will be a licensed Canadian physician; if they are being purchased in more than one Selected Country, an Agent Physician will be engaged in each Selected Country in which My Pharmaceuticals are being purchased, in connection with those of My Pharmaceuticals being purchased in that Selected Country.

3.04      I further consent to each Agent Physician and My Doctor being able to contact one another to discuss my medical condition, as it pertains to the prescribing of My Pharmaceuticals. I understand that the reason for this consent is to provide each Agent Physician with the full opportunity to conduct an independent analysis of whether My Prescription is appropriate, and discuss any potential medical complications that might 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 agree to regularly visit My Doctor and to promptly advise the Agent Physician and THS of any changes to my medical condition or prescriptions. It is clearly understood that I am not seeking medical treatment or service of any kind from any Agent Physician, THS or My Agents with regard to any medical advice or treatment of any kind whatsoever. I have relied only on My Doctor in respect of My Prescription.

3.05      I hereby specifically acknowledge that I am aware that THS will be transmitting my personal health information by electronic means (for example fax, or secure internet) to My Agents. I understand that the use of electronic means will enhance the efficiency and timeliness of processing understand that THS, 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 THS transmission of my personal health information by electronic means to My Agents.

3.06      If I was directed to THS's services through an intermediary (for example Pharmacy Benefit Manager, Health Management Organization or other service provider), I hereby authorize THS to release the following data to such an intermediary: a numerical identifier indicating that I was referred from that source; and financial information that will permit the processing of any claims on my behalf. It is my understanding that all such intermediaries will provide confidentiality covenants to THS whereby they agree to hold any such information in strictest confidence and to abide by the privacy policies of THS relating to the protection of my personal health information. I specifically consent to the transmission of the forgoing information to such intermediaries by electronic means.

3.07      Subject specifically to Sections 1.01 above and 5.01 below, I authorize and appoint THS and My Agents as my agents and attorneys for the purpose of taking all steps and signing all documents on my behalf necessary to package or re-package My Pharmaceuticals and to deliver them to me, to the same extent as I could do if I were personally present taking those steps and signing those documents myself.

3.08      Subject specifically to Sections 1.01 above and 5.01 below, I authorize and appoint THS and My Agents as my agents and attorneys for the purpose of taking all steps and signing all documents on my behalf necessary for shipping My Pharmaceuticals to me as if I had done so myself.

3.09      I acknowledge and agree that I initiated a consultation with THS. I also acknowledge that My Agents contracted by THS on my behalf are located either in Canada or in a Selected Country and those of My Agents that are physicians or pharmacists are licensed to practice medicine or pharmacy in Canada or in a Selected Country, as the case may be, and that all services that I receive from THS and My Agents are being received (to the extent that My Pharmaceuticals are purchased in Canada) in Canada or (to the extent that My Pharmaceuticals are purchased in a Selected Country) in that Selected Country.

PART 4 - AUTHORIZATIONS AND CONSENT

4.01      THS will for itself (in connection with any of My Pharmaceuticals that are being purchased from a Canadian pharmacy), and as agent for the dispensing pharmacy (in respect of any My Pharmaceuticals that are being purchased from a non-Canadian pharmacy) charge my credit card the following amounts:

1. the pharmaceuticals price and shipping charges (in Canadian dollars or US dollars, as determined by
2. THS) as posted on the THS web site on the day THS receives My Order and all other documentation (including the Equivalent Prescription) necessary for THS to fill My Prescription; and
3. in the event my payment is not authorized, THS has the right to cancel My Order and attempt to provide me with notice of such cancellation.

4.02      I acknowledge and agree that:

1. My Pharmaceuticals will be packages in child protected packaging, unless requested by me on the Patient Profile;
2. THS and My Agents shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available, unless My Doctor indicates that there be "no substitution".
3. once purchased and shipped, nopharmaceutical product may be returned or exchanged;
4. THS and My Agents reserve the right to refuse to assist me in obtaining My Order or any other order in their sole discretion, in which event I will be entitled to a refund for monies paid for such order;
5. neither THS nor My Agents provide their agency or attorney services as a substitute for healthcare or the advice of my primary care physician; and
6. neither THS nor My Agents will exchange pharmaceuticals or return any monies paid once an order is filled, unless the pharmaceuticals provided to me by the supplying pharmacy do not correspond with my prescription.

4.03      I SPECIFICALLY ACKNOWLEDGE AND AGREE THAT EACH AND EVERY OF THESE TERMS AND CONDITIONS (INCLUDING, WITHOUT LIMITATION, MY CHOICE OF DISPENSING PHARMACY) WILL AUTOMATICALLY, AND WITHOUT FURTHER ACTION BY ME OR THS, APPLY TO AND GOVERN ANY FUTURE ORDERS BY ME OF PHARMACEUTICALS FROM THS UNLESS I SPECIFICALLY INDICATE OTHERWISE AT THE TIME OF ORDERING SUCH PHARMACEUTICALS. WITHOUT LIMITING THE FOREGOING, EACH AUTHORIZATION AND CONSENT PROVIDED BY ME IN THIS AGREEMENT WILL CONTINUE UNTIL I REVOKE SUCH AUTHORIZATION OR CONSENT (WHICH I CAN DO AT ANY TIME).

PART 5 - GOVERNING LAW / DISPUTES

5.01     I specifically acknowledge and agree that any and all agreements reached or contracts formed throughout the course of my purchase of My Pharmaceuticals are and shall be deemed to be made:

1. in respect of any of My Pharmaceuticals that are purchased in Canada, in the Province of Manitoba, Canada and accordingly shall be governed by the laws of the province of Manitoba and the laws of Canada applicable to such contracts and agreements; and
2. in respect of any of My Pharmaceuticals that are purchased in a selected country, in that selected country and accordingly shall be governed by the laws of that selected country applicable to such contracts and agreements.

5.02      I specifically acknowledge and agree that any dispute that arises between me and THS or any of My Agents shall:

1. in so far as such dispute relates to THS or any of My Agents located in Canada, be goverened by the laws of the Province of Manitoba and the laws of Canada applicable to contracts formed in Manitoba, and the courts of the Province of Manitoba shall have sole and exclusive jurisdiction over any such dispute; and
2. in so far as such dispute relates to any of My Agents located in a selected country other than Canada, be governed by the laws of that selected country applicable to contracts formed in that selected country, and the courts of that selected country shall have sole and exclusive jurisdiction over any such dispute.