Patient Authorization
KamaHealth is a prescription referral service that connects patients with licensed Canadian pharmacy in White Rock, British Columbia, Canada, which are fully licensed by the provincial regulatory authority where they are located and staffed by fully licensed pharmacists. The following terms and conditions govern the sales as between the authorized dispensary and the individual regarding the products and services offered for sale by the Pharmacy. The Patient herein represents 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 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. This authorization may be revoked at any time and shall continue until I revoke it.
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.
