Please read both pages. With your initial and signature, you allow Chester Pharmacy to despense medication per prescription from your U.S. physician. Include your prescription(s) and eithr fax to 567-661-1990 or mail to: Seniors Source Inc., Order Department, 1581 Brittany Court Wheaton IL 60187. The pharmacy cannot fill any prescriptions without copies of your prescription or until signed and dated copies of these documents are completed. Questions? We offer personal service. Visit www.seniorsmedsource.com Call 630-248-1990. _______________________________________________________________________________________________________________________

LIMITED POWER OF ATTORNEY & RELEASE FORM

Customer Agreement

BY SIGNING BELOW, I, ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS AND SUCCESSORS, HEREBY AGREE TO ALL OF THE FOLLOWING TERMS AND CONDITIONS. I HAVE HAD ADEQUATE OPPORTUNITY TO CONSULT MEDICAL, LEGAL OR OTHER ADVISORS AND REPRESENT THAT I UNDERSTAND ALL OF THE FOLLOWING TERMS AND CONDITIONS.

Disclosures and Representations

I represent and confirm to 665883 Ltd. dba Chester Pharmacy (Chester Pharmacy) and Seniors Medsource Inc. (Seniors Medsource, d.b.a. Seniors Source Inc.), its affiliates, related companies, and subsidiaries (hereinafter collectively referred to as the "Companies") that all the following statements are true and agree that the Companies and their contractors, employees and agents are relying on these representations and documentation. I also agree to notify the Companies and to provide updated information based on any changes to my medical or physical condition.

1. I am of the age of majority or older according to the laws of the country, state or other applicable jurisdiction in which I reside.
2. I can make my own medical decisions according to the laws of the country, state or other applicable jurisdiction in which I reside.
3. The prescription drugs that I am ordering were prescribed by a doctor licensed to practice medicine in the country, state or other applicable jurisdiction in which I reside or where I had treatment and the prescription(s) I obtained was lawfully obtained.
4. The prescription that I am arranging to have the Companies assist me in obtaining has not been altered in any way nor has it been filled prior to submission to the Companies. I agree to immediately destroy all copies of my prescription once it has been filled.
5. I will use any medication obtained for me by the Companies strictly in accordance with the instructions provided by the physician who prescribed the medication(s).
6. I am under the ongoing care of a qualified U.S. physician and have consulted that physician within the last year and therefore I am not seeking or relying on any medical information from the Companies.
7. This order for prescription drugs is for my sole use and will be used only by me.
8. I will immediately contact Chester Pharmacy, who provided my prescription(s) to be filled under this order in the event I suffer any unexpected side effects from any medication(s) obtained for me by the Companies.
9. The Companies have made no representations or warranties to me, including, without limitation, representations or warranties with respect to the usefulness or fitness for a particular purpose of the medication(s) delivered (including, without limitation, its appropriateness for curing or helping relieve any particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown).
10. I understand that it is my responsibility to have regular physical exams given by my licensed U.S. physician and to take all suggested testing to minimize the chances of any unexpected side effects related to the medications provided.
11. I have fully disclosed all pertinent information and documentation to the Companies.
12. I undertand that according to the bylaws of the College of Pharmacists of British Columbia, Bylaws 5-33:1 "No registrant may accept or return to stock or reuse drugs previously despensed".

Initials here ________________

Releases and Discharges

I hereby release and discharge the Companies and each of their employees, officers, agents, contractors, Canadian physicians and other representatives from all present and future claims, causes of action and liabilities in regard to the appropriateness, suitability, strength and dosage of the prescription drugs prescribed for me by the U.S. physician and requested by me and delivered to me by the Companies, including, without limiting the generality of the foregoing any injuries or damage sustained by me arising by reason of any side or ill effects whatsoever of any kind or nature.

I did not and will not rely on the Companies or any of their employees, officers, agents, contractors, Canadian physicians and other representatives regarding the prescription drugs that are supplied to me by the Companies other than that such prescription drugs will be equivalent to the prescription drugs prescribed. I agree to accept generic drugs if they are allowed by my prescription and if I have authorized them on the order form.

I acknowledge and agree that the prescription drugs may not be packaged in child protective packaging.

I release and discharge the Companies and each of their employees, officers, agents, contractors, Canadian physicians and other representatives from all causes of action with respect to the late delivery, non-delivery or missed delivery of prescription drugs.

Nothing in this release shall be deemed to release Chester Pharmacy or its pharmacists from compliance with the applicable standards of practice or usual professional duties and obligations that a pharmacist owes.

Authorizations and Consents

I hereby authorize and appoint the Companies as my agent and as my attorney for the limited purpose of doing all acts, signing all documents and taking any and all other steps, for and on my behalf, which are reasonably necessary to obtain for me a prescription(s) in Canada that is equivalent to the prescription(s) provided to the Companies all to the same extent that I could do if I were personally present and performing those acts, signing those documents and taking those steps myself.

I further authorize and appoint the Companies to have the Canadian prescription filled for me in Canada by Chester Pharmacy of Delta, British Columbia, Canada.

I also authorize the Companies to directly contact my prescribing U.S. physician to obtain further information if required. I understand and agree that my personal health information may be seen by the Companies and their employees, agents, contractors, physicians, pharmacists and pharmacy technicians and that this information will be kept as required for the limited purpose of obtaining a prescription and completing my order in Canada. I also acknowledge and consent to the transmission of my personal health information by electronic means as part of the ordering process.

I further authorize and appoint the Companies as my agent and attorney for the purpose of completing those acts, signing those documents, and taking such other steps on my behalf which are necessary to have my prescription drug order shipped on my behalf to my address as provided on the Pharmacy Order Form and on the copy of the government ID provided to the Companies to the same extent as if I myself arranged for such shipping and consigned the prescription drug order to the shipper for such shipping.

I acknowledge and agree that I contacted the Companies and that Chester Pharmacy is not located in the United States. I also acknowledge that the pharmacists working for Chester Pharmacy and the physicians contracted by Chester Pharmacy on my behalf are located and licensed to practice medicine or pharmacy in Canada and that all services that I receive from Chester pharmacy and the pharmacist are being carried out in Canada.
I agree that any and all agreements reached or contracts formed throughout the course of the relationship between me and the Companies shall be deemed to be made in the Province of British Columbia, Canada and accordingly shall be governed by the laws of the Province of British Columbia and the laws of Canada applicable to such contracts and agreements.

Initials here ___________________

I also agree that any dispute that arises between me and the Companies, its affiliates, employees, officers, directors, agents, contractors, Canadian physicians and other representatives shall be governed by the laws of the Province of British Columbia and the laws of Canada applicable to contracts formed in British Columbia, and I agree that the courts of the Province of British Columbia shall have sole and exclusive jurisdiction over any such dispute. As such, I acknowledge that Chester Pharmacy is duly licensed in the province of British Columbia, Canada by the college of Pharmacists of B.C. The College of Pharmacists of B.C. can be contacted at Suite 200-1765 West 8th Avenue, Vancouver BC, Canada, V6J 5C6. I acknowledge that I can contact the college of Pharmacists of B. C. to report my concerns.

The authorizations and consents that I have given commence on the date I have signed this Agreement and shall continue until I revoke them and I can revoke the Authorizations and Consents I have granted to the Companies at any time.

Terms of Purchase and Sale

Chester Pharmacy will charge my credit card for the products ordered plus a shipping charge of US$12.95 per package
If my payment is not honored, the Companies will attempt to advise me and have the right to cancel my order.
The prescription drugs may not be packaged in child protected packaging.
No prescription drug products may be returned or exchanged after shipment.
The Companies shall be entitled to substitute a generic prescription drug for a brand name prescription drug, where available, unless the physician has indicated that there be "no substitution" or the Pharmacy Order Form specifies "no generics".
The Companies reserve the right to refuse to assist me in obtaining any order at its sole discretion. I will be entitled to a refund of any monies paid for such order.
The Companies do not provide its services as a substitute for healthcare or the advice of the customer's primary care physician.
The Companies have relied and will be relying on the information and documentation provided by me and I represent that I have, to the best of my knowledge, fully disclosed all information and documentation that is relevant.

I HAVE READ AND UNDERSTOOD THE ABOVE TERMS AND CONDITIONS AND AGREE THAT THEY SHALL BE BINDING UPON MYSELF AND MY HEIRS, PERSONAL REPRESENTATIVES AND OTHER LEGAL REPRESENTATIVES, AND BY MY INITIALING EACH PAGE I HAVE CONSENTED TO THE TERMS CONTAINED ON EACH PAGE.

Signature:___________________________________ Date: _____________________

Please attach your prescriptions here.