Release and Waiver of Liability, Assumption of Risk, and Indemnity Form | CompreCareRx Pharmacy

Release and Waiver of Liability, Assumption of Risk, and Indemnity


  • READ THIS RELEASE CAREFULLY BEFORE SIGNING IT. YOUR SIGNATURE INDICATES YOU UNDERSTAND IT AND AGREE ON ITS TERMS. BY SIGNING THIS RELEASE, YOU ARE GIVING UP CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE OR RECOVER DAMAGES IN CASE OF LOSS OF MEDICATION OR FAILURE TO RECEIVE MEDICATION, FOR ANY REASON.

    The undersigned, residing at the address below, acknowledges this Release on behalf of themself.

  • I HEREBY:

    1. Acknowledge that I have given permission to CompreCare RX to ship my medication package to the address located below;

    2. Acknowledge that I have permission from the resident of the address to ship my medication there for receipt by me;

    3. Voluntarily assume the risk and potential loss of said package, should I not receive it upon or after delivery;

    4. Release, discharge, indemnify, and otherwise promise not to sue Pharmacy Associates, Inc. dba CompreCare RX and/or any of its owners, officers, employees, agents or affiliated entities (hereinafter the “Releasees”), for any loss, liability, damages, or cost whatsoever arising out of or related to any loss, damage, or injury I experience as a result of shipping my medication;

    5. Release the Releasees from any claim that such Releasees are or may be negligent in connection with my medication shipment;

    6. Expressly agree that this Release is governed by the State of West Virginia and is intended to be as broad and inclusive as is permitted by West Virginia law, and that in the event any portion of this Release is determined to be invalid, illegal, or unenforceable, the validity, legality and enforceability of the balance of the Release shall not be affected or impaired in any way and shall continue in full legal force and effect;

    7. Acknowledge that this Release forms a contract and agree that if a lawsuit is filed against CompreCare RX or the Releasees for any reason in breach of this contract, I will pay all attorney’s fees and costs incurred in defending such an action;

    8. Am eighteen (18) years of age or older.


  • I understand that CompreCare RX will verify that I have permission to ship to the above address and will ask the recipient signer for certain identifying information about me to verify their relationship with me, and ability to accept medication shipment on my behalf. I understand that this must be verified and completed prior to my next shipment. If this information is not verified it may delay my shipment.


    I have read this entire Release. I understand, acknowledge, and consent to its terms by signing below:

  • Date Format: MM slash DD slash YYYY