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Customer Registration Information

To register DUB Group Pharmacy Program, fill in the form below. Items listed in bold must not be left blank. All information will be kept strictly confidential.
Personal Information:
Shopper's Login ID:   The name for login online to track orders.
Password   4 to 10 characters or numbers.
Verify Password   Match exactly.
Challenge Question   Reset password question.
Challenge Answer   Reset password answer.
Title
Last Name
First Name
Middle Name
Birth date DD/MM/YYYY
Gender
Group Name DUB
Contact Information:
Address (line 1)
Address (line 2)
City
State
Post Code
Country
Daytime Phone Number only digits, no space. eg.4164446666
Evening Phone Number only digits, no space. eg.4164446666
Fax Number only digits, no space. eg.4164446666
E-mail
Best Time to Call
Doctor Information:
Doctor's Last Name
Doctor's First Name
Doctor's Phone Number only digits, no space. eg.4164446666
Doctor's Fax Number only digits, no space. eg.4164446666
Doctor's E-mail
Select one: Doctor phone/fax your prescription
Pharmacy calls your doctor
You are now ready to submit your registration for approval. To submit your registration, click the Submit button.

Prior to submitting my personal profile, I acknowledge that I have read the following Limitation of Liability and Disclaimer and agree that:

1. The information available through this site is intended to assist in selecting non-prescription products and does not suggest diagnosis or treatment. This information is not a substitute for medical advice, treatment or attention.

2. I understand that neither Pharmacy nor this website has made any representations or warranties whatsoever. Without limiting the generality of the foregoing, neither Pharmacy nor this website has provided any representations or warranties of merchantability, fitness for a particular purpose or diagnosis. Further, neither Pharmacy nor this website represent or warrant that the information accessible on this website is accurate, complete or current.

3. Price and availability information is subject to change without notice.

4. Except as specifically stated on this site, neither Pharmacy nor any of its officers, directors, employees, agents or representatives will be liable for any damages of any kind arising out of, or in connection with, the use of this website. Without limiting the generality of the foregoing, there shall be no liability for damages of any kind including compensatory, direct, indirect or consequential damages for personal injury of any kind or for any reasons, including for loss of data, income or profit, loss of or damage to property and claims of third parties.

The use of this website and all agreements relating thereto are governed by the laws of the Province of Ontario. Any actions commenced with respect to this website or Pharmacy shall be adjudicated in the Province of Ontario. All users agree to attorn to Ontario for these purposes.

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Oct 1st. 2004.