Enrollment

MCG100SW MagnaCare: Customer Profile

Getting Started….

· Completely fill out the enrollment form

· Mail it in with your original prescription or have your physician fax (888-441-7722) it in for you. If medication is controlled, only the original prescription is accepted. The patient’s name and birth date MUST be written on the prescriptions.

First Name: ______________________________________

Last Name: ______________________________________

Address 1: _______________________________________

Address 2:_______________________________________

City: _________________________________

State: __________________________________

Zip Code: _______________

Country: ________________

Phone_Number:__________________________

Fax_Number:________________________________

Email Address: ______________________________

Date of Birth: _______________ Weight _______ lbs.

Gender: ____ male ____ female

Smoker?: ______ yes ______ no

Pregnant?: ______ yes _____ no

Nursing?: ______ yes ______ no

Medical Profile

Physician’s Name and Phone Number: _________________________________________________________________________

Please list all allergies: ______________________________________________________________________________________

List Current Medications: ____________________________________________________________________________________

Please state Current Medical Condition/Diseases: ________________________________________________________________

________________________________________________________________________________________________________

Method of Payment

(Please CIRCLE one)

VISA

MASTERCARD

DISCOVER CARD

AMERICAN EXPRESS

Name as it appears on Credit Card:________________________________________

Credit Card Number: ___________________________________________________

Expiration Date :______________

Signature of Cardholder: ________________________________________________

(By signing here, you authorize the pharmacies to keep your credit card on file and bill future orders on this credit card.)

Release Form: This form must accompany the enrollment form along with your first prescription. No prescriptions will be filled without a signed and dated copy of this form The undersigned, being over the age of 21, hereby:

1. Represents and confirms to CarePharm/RF Drugstore that the pharmaceutical(s) to be delivered to the undersigned 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;

2. Releases and discharges CarePharm/RF Drugstore and all of their agents, affiliates and employees, from any and all liability, claims or causes of action with respect of the appropriateness, suitability, strength or dosages of the pharmaceutical(s) prescribed for the undersigned, including, without limiting the generality of the foregoing, any side or ill effects whatsoever of any kind or nature, and confirms that the undersigned did not rely on CarePharm/RF Drugstore with respect to the nature of the pharmaceuticals prescribed, other than to fill the prescription in accordance with its plain terms. The undersigned understands and acknowledges that the pharmaceutical(s) will not be packaged in child protective packaging and the undersigned releases and discharges CarePharm/RF Drugstore all of their agents, affiliates and employees from any and all causes of action with respect to the non-delivery or misdelivery of the pharmaceutical(s) sent to the undersigned.

3. Authorizes and appoints CarePharm/RF Drugstore as his or her agent and as his or her attorney for the limited purpose of taking all steps and to sign all documents on behalf of the undersigned necessary to deliver the prescription documents from CarePharm/RF Drugstore in the form required by the State of Texas and Province of Manitoba law to CarePharm/RF Drugstore where it will be filled and returned to CarePharm/RF Drugstore sent by it to the undersigned as if the undersigned were personally present in the State of Texas, USA/Winnipeg, Province of Manitoba, Canada, and taking those steps and signing those documents him or herself.

4. Authorizes and appoints CarePharm/RF Drugstore as his or her agent and as his or her attorney for the purpose of taking all steps and to sign all documents on behalf of the undersigned necessary for shipping his or her prescribed pharmaceuticals to the undersigned as if the undersigned has shipped the prescribed pharmaceuticals to himself or herself from Texas, USA/Manitoba, Canada, to the undersigned's address.

5. Agrees that the courts of Texas, USA/Manitoba, Canada, shall hear any dispute that arises between him or her and CarePharm/RF Drugstore that the courts of Texas, USA/Manitoba, Canada shall have the sole and exclusive jurisdiction and that the law of the U.S.A./Canada shall apply to any and all disputes that may arise.

THE UNDERSIGNED HAS READ AND UNDERSTANDS THESE TERMS AND AGREES THAT THEY SHALL BE BINDING UPON THE UNDERSIGNED AND HIS OR HER HEIRS, SUCCESSORS AND PERSONAL REPRESENTATIVES.

Notice: Federal Law prohibits the resale of previously dispensed pharmaceuticals; therefore, you may not return medication for refund or exchange.

________________________________________________________________

Patient Signature

________________________________________________ _______________

Print Name Date