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 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. The undersigned releases and discharges 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 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 RF Drugstore in the form required by Province of Manitoba law to RF Drugstore where it will be filled and returned to RF Drugstore sent by it to the undersigned as if the undersigned were personally present in Winnipeg, Province of Manitoba, Canada, and taking those steps and signing those documents him or herself.

4. Authorizes and appoints 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 Manitoba, Canada, to the undersigned's address.

5. Agrees that the courts of Manitoba, Canada, shall hear any dispute that arises between him or her and RF Drugstore that the courts of Manitoba, Canada shall have the sole and exclusive jurisdiction and that the law of 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.

• I have taken every precaution to access knowledge in pricing/shipping
information from RF Drugstoreprior to registration.

• I give RF Drugstore authorization to bill my Credit Card in
terms to agreeing with the prices that have been provided to me.

• I am aware that all prescriptions that I or my doctor are sending to RF Drugstore contain medications that have been prescribed to me and I am agreeing to have all prescriptions that I have sent filled by your pharmacy.

• I am aware that I cannot return/refund medications that have already been sent out to me.