Rx 'n Go Beyond Pharmacy Profile Form

Please read through and agree to the following terms and conditions to access the form:


I enter into this Agreement, so that I may obtain Medication from the Rx 'n Go Program through personal importation, and therefore represent the following.

  • I have sufficient medication available for the next 30 days.
  • I agree to have the Rx 'n Go Beyond program facilitate the personal importation of my medications through Westview Pharmacy located in Canada.
  • I consent to having Rx 'n Go Beyond act as my Agent and help facilitate the personal importation of my medication(s).
  • I understand that the personal importation of my medicine will take 3-4 weeks to arrive.
  • I am able to self-administer the medication if it is an injectable product.
  • I am responsible for understanding the full Terms & Conditions listed below.

This Agreement incorporates our Privacy Policy here as though fully set forth herein.

  1. I am a resident of the United States (the "U.S.") and am the age of majority in the jurisdiction where I reside.
  2. I am not restricted from making my own medical decisions.
  3. I have been examined and received a lawfully issued prescription ("My Prescription") from a U.S. licensed healthcare practitioner ("My Practitioner").
  4. I will remain within the regular care of My Practitioner throughout the course of me taking any Product ordered through the Program.
  5. I have been taking the Product that I have ordered from the Program for at least 30 days prior to placing an Order for that Product.
  6. My Prescription has not been altered in any way, nor has it been filled previously.
  7. I will use any Medication obtained from the Program strictly in accordance with the instructions provided by My Practitioner, the Program and/or the manufacturer of the Product.
  8. I will not permit anyone else to use My Prescription or any Product which I receive from the Program.
  9. In the event I suffer any side effects from any Products, I will immediately contact My Practitioner.
  10. I will immediately inform the Program about any changes to my health.

I consent to, and authorize, the following:

  1. I hereby appoint the Program and its authorized delegates and contractors as my agent and attorney for the purposes of obtaining Product which corresponds to My Prescription from the Program.
  2. The Program may perform any act that I could myself for the purposes of having My Prescription reviewed by a physician, pharmacist and/or pharmacy technician, and having the Product dispensed by a Pharmacy and delivered to me.
  3. My Practitioner may release to the Program (and any authorized agents of the Program, including contracted physicians, pharmacists, and/or pharmacy technicians) any and all of my personal health information, including but not limited to, my full medical records, progress notes, nurses’ notes, diagnostic test results, imaging records, laboratory testing reports, and/or any other medical knowledge or information which My Practitioner may possess ("Personal Health Information").
  4. I agree to request My Practitioner to issue My Prescription on paper (if necessary, for dispensing by a Pharmacy located outside My Practitioner’s jurisdiction) and to send (by mail, by fax, via the internet or otherwise) to the Program from My Practitioner’s office the original signed copy of My Prescription.
  5. The Program and its contracted physicians, pharmacists and/or pharmacy technicians may contact My Practitioner to discuss My Prescription as they find necessary.
  6. A Program contracted physician may issue prescriptions for medications I have ordered if they deem it advisable and appropriate.
  7. The Program may make payments on my behalf to the Pharmacy for dispensing Product in accordance with My Prescription and/or to the Program’s contracted physicians for services rendered on my behalf.
  8. That I request and authorize my employer, to pay for all Products and services relating to the Product that I obtain through the Program in such amounts as are found appropriate by my employer in accordance with the design of my health benefit plan choice.

ECB Rx, LLC dba Rx 'n Go Beyond ("Rx 'n Go")™ is a marketing entity organized under the laws of Manitoba. It owns and operates [www.rxngobeyond.com] (the "Site") that may be used by consumers ("You" or the "Member") for the purposes of assisting the Member in obtaining pharmaceutical products ["Product(s)"] from licensed pharmacies and/or government approved dispensaries located in various jurisdictions located throughout the world (collectively, the "Pharmacy"). As the Member’s authorized agent and attorney, Rx 'n Go and its third party partners will work the Pharmacy to facilitate orders of Product ("Orders") for maintaining the Member’s health and well-being (collectively, the "Program"). Since You do not necessarily reside in the same jurisdiction where the Products will be coming from, it is necessary for You to authorize Rx 'n Go and those authorized agents involved in the Program to act on behalf of the Member. By accepting delivery of the Products and services from the Program, You agree to be bound by these terms and conditions of sale (collectively, "Terms & Conditions").

The Member hereby certifies that he/she has read, understands and agrees to the terms set out in these Terms & Conditions and Rx 'n Go Beyond’s Customer Agreement, and that all the information provided by Member are accurate and true. If any of my information provided changes, or is later found to be inaccurate or untrue, it is the Member’s legal responsibility to immediately change and/or update the information so that it is accurate and true.

I am registering a Member that is a dependent of mine and under the legal age of majority in the jurisdiction where I reside (the "Dependent"). Therefore, I hereby certify that: (i) I have provided a true and accurate statement as to the medical history of the Dependent; (ii) the Dependent has been examined by a licensed prescriber ("Prescriber") within the last 12 months, and will be examined at least once every 12 months by a Prescriber while he or she is taking the Product; (iii) the Dependent has taken the Product to be filled by the Program for at least 30 days, and has not experienced any adverse symptoms or reactions; and (iv) I have read, understand and agreed to these Terms & Conditions. If any of the information about my Dependent changes, or is later found to be inaccurate or untrue, it is my legal responsibility to immediately change and/or update the information provided so that it is accurate and true.


Welcome to [www.rxngobeyond.com] (the "Site"). This User Agreement (the "Agreement") is entered into between You and the Program so that You or the Dependent may obtain access to Products, and other related services, provided by the Program.

By completing the registration process, You agree to accept the Terms and Conditions as a condition of becoming a Member. Rx 'n Go has the absolute right to change the terms of this Agreement as it deems fit. However, if Rx 'n Go changes this Agreement, it shall post a revised version of the Agreement on the Site, which shall automatically replace the terms of this Agreement. Continued use of the Site and the Program following the posting of a revised Agreement will constitute the Member’s acceptance of the revised Agreement. If You do not agree with the terms of this Agreement, or any revised version of this Agreement, You must no longer continue to use the Program [or this Site].

I hereby make the following acknowledgements and releases to the Program and all its employees, delegates, agents, and contractors, including physicians, pharmacists, pharmacy technicians and customer service staff:

A. That My Practitioner is my primary healthcare provider and that the Program contracted physician is being asked to review my Personal Health Information only for the purpose of authorizing the Product to be dispensed to me by the Pharmacy.

B. That the Program has made no representations or warranties to me, including, without limitation, representations or warranties regarding the use of fitness for any particular purpose of the Product delivered, 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.

C. That I wish to obtain a prescription from a by the Program contracted physician and have enlisted the services of the Program to facilitate such, and that I understand that the Program contracted physician will rely on the accuracy of the examination performed, and the prescription provided, by My Practitioner.

D. That I release the Program and all of its officers and directors, agents, delegates, employees and contractors from any and all liability, claims, and causes of action with respect to loss, delays, errors or omissions by the company or agency responsible for transporting My Medication order to the U.S. located address provided to the Program by me.

E. That I have sourced the Product for my personal use and understand that it may be subject to U.S. Customs inspection. Not all Products offered for sale by the Pharmacy are United States Food & Drug Administration ("FDA") approved. Please note that the FDA has taken the position that virtually all shipments of Products imported from the Pharmacy by a U.S. resident will violate United States law. By placing an order for Products or services with the Program and/or the Pharmacy, I represent that sale, delivery, and shipment of the Products will not violate any import, export, or other law or regulation in my home jurisdiction.

F. That I specifically confirm, acknowledge and agree that title to the Product passes to me when it leaves the Pharmacy. After delivery, the Pharmacy will, as authorized agent and attorney, arrange for the shipping of the Products to your home address. Normally, shipments take an average of two (2) – four (4) weeks to arrive. In the event that shipment of the Products is delayed, and upon notice from you, the Pharmacy will arrange for a replacement order to be sent to you at no additional cost. The Program is not liable for any damages suffered due to delay in shipment or failure of the Products to arrive within a specified number of days.

G. That the Product may not be returned for any refund or exchange.

H. That child protective packaging may be used in filling My Medication, however if I decline child protective packaging or if child protective packaging is not suitable, then I therefore will take all steps necessary to prevent any child from having unauthorized access to My Medication.

I. That I release the Program and all its officers, directors, agents, delegates, employees, and contractors from any and all claims arising from or relating to the misuse of child protective packaging.

I hereby certify that I have read, understand and agree to the terms of this Agreement, and that all the information provided by me are accurate and true. If any of my information provided changes, it is my sole responsibility to immediately update the information provided so that it is accurate and true.


Consider adding some other provisions to cover off, including:

Return Policy. The Program does not accept return of Products for any credit unless the Products were dispensed in error contrary to the prescription or a delivery error occurred. Please visit the Site to view the current return policy for Products.

Force Majeure & Delays in Shipment. The Program shall not be liable for any delay or failure in performance caused by circumstances beyond their reasonable control including, without limitation, delays due to back orders of requested Products, mail delays, customs delays and lost shipments. Although the Program will make reasonable efforts to do so in order to maintain good client relations, the Program is not responsible to notify you in the event of any delay. You shall be solely responsible to make such arrangements or to purchase alternative products. Any such costs incurred in association with such purchases shall be solely borne by you. In cases where the original order is received by the plan member after a reship order has been processed Rx 'n Go Beyond will invoice my employer for both orders, and adjust the due date for the next refill order accordingly.

Governing Law. You understand that Rx 'n Go is a marketing company that engages the Pharmacy, in its capacity as your authorized agent and attorney, for the purpose of facilitating the purchase of the Products. Title to the Products pass to you when they leave the Pharmacy. All agreements reached or contracts formed shall be deemed to have been made in the jurisdiction of the Pharmacy, and the laws of that jurisdiction shall have sole and exclusive jurisdiction over any dispute arising between you and the Pharmacy and/or under these Terms & Conditions.

I Agree