TTB Order - CompareMedsRx

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Please fill out your contact information.

First Name *

Last Name *

Street Address *

Include Apt, Suite, etc. (if applicable)

City *

State *

Zip Code *

Mobile Phone *

Home Phone

Email *

Please fill out your health information.

Date of Birth

MMDDYYYY

Gender

Height *

Feet (ft)

Inches (in)

Weight *

(Pounds)

Drug Allergies *

Yes

If yes, what are they?

Are you a smoker? *

Yes

Are you pregnant or trying to get pregnant? *

Yes

Please list all medications, OTC, or Herbal Products you are currently taking.

Medication Name

Ex: “Atorvastatin”

Strength

Ex: “40mg”

Frequency

Ex: “Twice a day”, “Once in the morning”, etc

Please confirm your requested prescription is correct, review our terms and conditions, and sign.

Medication Order

Medication Name

Strength

Quantity

Please click to review our terms and conditions. *

I am confirming; I am over the of the age of majority in the jurisdiction where I live and fully agree to the Terms and Conditions of Sale 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 representation listed in the Terms and Conditions of Sale to the pharmacy on the patient's behalf.

I consent

Please Sign & Date

Full Name *

Signature *

Today’s Date *

Send us your prescription and enter your physician’s information.

Please send your prescription(s) via one of these options:

Email a scan to support@toptierbenefits.com
Fax a copy to: 1-877-824-9741
Or upload a copy of your prescription to this form for submission below

Upload Your Prescription If Available Here

If you are taking a picture of your Rx to submit, please ensure the photo is clear and the entire prescription is included.

Drag & Drop files here

Upload Document

Don’t have your prescription handy?

Have your doctor’s office send it to us directly via fax, email, or phone
Reach out to us at support@toptierbenefits.com and we’ll request it for you.

Physician Information

Physician Name *

Clinic Name *

Street Address *

Include Apt, Suite, etc. (if applicable)

City *

State *

Zip Code *

Clinic Phone *

Clinic Fax

Physician Email *

Your Home Delivery Request for

Has Successfully Been Submitted!

Here’s what you can expect next

A Top Tier agent will call you to confirm your order, or, you will get a text message with a link taking you to the patient portal.

Agents can process your payment via phone, or you have the option to pay using the patient portal.

Your medication will be shipped to your door!

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Top Tier Benefits, Inc (TTB) specializes in the provision of distance-based pharmacy care and mail-order delivery of pharmacy medicine from the contracted pharmacy located at 123 St. Anne's Rd, in Winnipeg, Manitoba, Canada. The following terms and conditions apply to all sales and delivery of pharmaceuticals between TTB, the contracted pharmacy and you, the patient. By accepting delivery of the products and services from TTB and the contracted pharmacy, you agree to be bound by and accept these terms and conditions of sale.

About You. By placing an order with TTB, you acknowledge that you are of the age of majority in the jurisdiction where you live, are entitled to make your own medical decisions, are of sound mind, and understand and consent to these terms and conditions of sale without undue influence or duress. You acknowledge that these terms of sale are readily accessible on a 24-hour basis on the TTB website (located at www.toptierbenefits.com/ termsandconditions) and that you have every opportunity to obtain independent legal advice with respect to them.

Prescription Required. You acknowledge that TTB will not accept any prescription medication order unless we receive a valid prescription from you. A prescription being issued by a licensed practitioner based upon and after the appropriate personal examinations as determined by your home jurisdiction's medical standards of practice.

Your Prescription. A qualified and licensed physician lawfully prescribed the medications you have requested. You have attended, had a physical examination, received a prescription from a duly licensed practitioner within the last year, and do not require an additional physical examination. You have not altered your prescription in any way. The duty of care with respect to the prescribing of your medications is and shall remain the responsibility of your physician. You will consult with your physician for any appropriate monitoring and testing. You will use your medication only as directed by your physician and will remain under the care of your physician while taking your medication. Except as explicitly authorized by law (and further clarified herein), you are not purchasing medications for anyone else and will be the only person using the medication obtained from TTB. In the event that you are unable to personally place your order with TTB (and its Partners) due to age or infirmity, you can authorize someone else to place your order and assist you in acquiring your medications, so long as they have power of attorney over your affairs and provide a copy of their legal authorization to act on your behalf to TTB.

Power of Attorney. You expressly grant to TTB (and its Partners) power of attorney to take all steps, sign all documents, and act on your behalf for the sole purposes of obtaining a prescription recognized and valid within the dispensing pharmacy's home jurisdiction, as well as packaging and shipping the medications to you. This authorization shall include, but not be limited to, the collection of your personal and private health information and the disclosure of such information to any pharmacist, physician, or other health professional being retained on your behalf, as required. TTB contracts with a licensed Canadian pharmacy operating out of Winnipeg, Canada, a pharmacy legally licensed and authorized by the College of Pharmacists of Manitoba and Health Canada to fill and dispense Canadian medications.

No Medication Returns. Medications cannot be returned for refund or exchange. Pursuant to Health Canada regulations and instructions, TTB cannot accept returned medications.

Privacy Authorization. You have fully and accurately disclosed your personal and health information to us and authorize TTB (and its affiliated businesses and partners) to collect and use your information for the fulfilment and delivery of your order. By submitting an order, you have consented to TTB's (and its Partners') collection and use of your personal information.

Products and Services. TTB may revise and discontinue any products and services at any time without notice. Please call us if you have any questions about TTB's products or services.

Delivery. Delivery of the medications you order takes place when they leave the pharmacy. After delivery, TTB will, as attorney and agent for you, arrange for shipment of the medications to your home address. Typically, shipments take an average of 14-21 days to arrive. In the event that your shipment is delayed, and upon notice from you, we will arrange for a replacement order to be sent to you. TTB is not liable for any damages suffered due to delays in shipment or failure of the product to arrive within a specific number of days. You release and discharge TTB's directors, officers, agents, and employees from any and all liability, claims actions or causes of action with respect to any errors or omissions by the carrier responsible for delivering your medication to you.

Warranties. THE MANUFACTURER OF EACH PRODUCT IS SOLELY RESPONSIBLE FOR ANY WARRANTY ASSOCIATED WITH THE PRODUCT. TO THE MAXIMUM EXTENT PERMITTED BY LAW, TTB DISCLAIMS ALL WARRANTIES AND CONDITIONS, EXPRESS OR IMPLIED, IN RESPECT OF THE PRODUCTS AND SERVICES CONTEMPLATED BY THESE TERMS OF SALE, INCLUDING, WITHOUT LIMITATION, IMPLIED WARRANTIES AND CONDITIONS OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. RESPONSIBILITY FOR CLAIMS IN RESPECT OF THE PRODUCTS IS LIMITED TO REPLACEMENT OF THE PRODUCT.

Severability. The invalidity and unenforceability of any provisions in these Terms and Conditions of Sale shall not affect the validity or enforceability of any other provisions hereof, and any such invalid or unenforceable provision shall be deemed to be severable.

Headings. The section headings used herein are for convenience of reference only and do not form a part of these Terms and Conditions of Sale. No construction or inference may be derived from them.

Governing Law. You acknowledge that if a TTB Partner dispenses your medications, then the pharmacy services are performed in the jurisdictions of the Partner pharmacy in the same way as if you had physically attended to the Partner's location. Any dispute, complaint, demand, claim, or cause of action relating to the Partner's services will be governed by the laws of the jurisdictions of the Partner pharmacy. In such event, you expressly attorn to the jurisdiction of the Partner pharmacy, and the courts of that jurisdiction will have sole and binding authority to settle any and all disputes.

YOU SPECIFICALLY CONFIRM, ACKNOWLEDGE AND AGREE THAT EACH AND EVERY ONE OF THESE TERMS AND CONDITIONS, WITHOUT LIMITATION, WILL APPLY AUTOMATICALLY AND GOVERN ANY PRESENT AND FUTURE ORDERS UNLESS YOU SPECIFICALLY INDICATE OTHERWISE AT THE TIME OF ORDERING. ANY AUTHORIZATIONS AND CONSENT INCLUDED IN THESE TERMS AND CONDITIONS WILL CONTINUE UNTIL YOU CANCEL THEM, WHICH YOU CAN DO AT ANY TIME. HOWEVER, IF YOU CANCEL YOUR AUTHORIZATION AND CONSENT, WE MAY BE UNABLE TO PROVIDE SERVICES TO YOU.

If at any time you have questions regarding our policies, please don't hesitate to contact us at support@toptierbenefits.com