Clinic Re-Seller Agreement Form Please enable JavaScript in your browser to complete this form.Please list the name of the practitioner responsible for ensuring compliance with this agreement *FirstLastPhoneEmail *Please indicate the name of the dispensary *Please indicate the address/location of the dispensary to which this agreement applies (Address #, Street Name, Province, Postal Code) *You and your dispensary have a policy in place to manage and dispense prescriptions.Your policy includes a process by which a practitioner registers with your facility, and s/he has been approved for providing prescriptions for patients.You assume full responsibility for the use and distribution of the item and hold Eastern Currents harmless from any liabilities, damages, or related losses that occur as a result of the improper use or distribution of the product.Herbal products supplied by Eastern Currents are not to be sold over the counter, nor are they to be placed in public spaces such as a retail store or open shelving.Products will be stored in a secured environment that does not permit public access.On-line sales from your personal website may be granted only for specific general use products that are not TCM related.Private prescription portals used by the clinic must require practitioner control with patient private login.The use of an online dispensing system must be compliant with the Canadian Personal Information Protection and Electronic Documents Act (PIPEDA).Products will be stored at an appropriate room temperature (18 to 28 degrees Celsius).All accounts are pre-approved based on the information supplied by the applicant. Eastern Currents will not be held liable for any falsified or inaccurate information provided, or any other damages or losses incurred as a result.This agreement approves the dispensary at the specific clinic or business location used in the registration process. Eastern Currents’ products, in part or in whole, are only to be sold at the certified location; their sale at any other location is strictly prohibited. If you have multiple locations, please request and complete additional forms as required.Eastern Currents maintains the right to cancel this agreement at any time, with or without advanced notice.Submit