Refill using Rx#
Pre-authorized Debit - Terms and Conditions
ACH PAYMENT AGREEMENT
- I hereby authorize Cloud Pharmacy Inc., located at 4918 Victoria Drive, Vancouver, BC, Canada to debit the account, detailed in the check image I provide, for the current and future orders placed by means of the Automated Clearing House (ACH) network as a Pre-Authorized Debit (PAD) payment.
- I confirm that I am entitled to authorize transactions for the bank account associated with the check image provided to bind and execute this agreement form.
- I will ensure that my account will have sufficient funds to pay for orders placed. I also acknowledge that failed billing attempts due to non-sufficient funds (NSF) may be subsequently re-billed with an additional $25 NSF fee.
- I shall indemnify Cloud Pharmacy Inc. and hold Cloud Pharmacy Inc. harmless against any and all claims, actions, loss, liability or expense (including attorney fees and settlement costs) resulting from or arising from this agreement.
- I confirm that the information conferred here either by myself, or by my agent, or by any member of Cloud Pharmacy Inc is accurate.
- This agreement was received, reviewed and confirmed by verbal and/or electronic communication; as such, by replying to and/or providing a check image, I thereby execute, agree, and authorize this agreement and associated current and future payments.
- This agreement will remain in effect until I notify, in writing, to Cloud Pharmacy Inc, to terminate this agreement.