CONTRACT FOR QUINN DISPENSING KIT

If you believe that the Quinn Dispensing Kit would benefit your patients and your practice, and if you dispense at least 20 remedies per month, we will be happy to send you a Quinn Dispensing Kit.

Please print this form, read it carefully, fill it out and fax or mail a copy to us with your initial payment.
Please allow 2 to 3 weeks for delivery of your Quinn Dispensing Kit.
Thank you.

Terms of Kit Consignment

This contract between Hahnemann Laboratories, Inc.(the Pharmacy) and

____________________ (you) is to provide you with a Quinn Dispensing Kit (the Kit) of Homeopathic Remedies for your office. Having the Kit in your office will benefit your patients by providing for the timely administration of the needed remedy. The Kit will contain several potencies of several hundred different Homeopathic Remedies, remedies selected by the Pharmacy and customized by you. Neither all possible remedies nor all possible potencies will be provided in the Kit.

The Kit will be consigned to you under the following conditions:

An account opening fee of $195.00 will be sent to the Pharmacy with your contract. The first two restocking fees of $400.00 each for the first two pages of the Log will be paid in advance, therefore the total due with this contract is $995.00.

Restocking of Kit

The Pharmacy will provide you with a Physician Dispensing Record Log Book (the Log) in which to record the remedies dispensed from the Kit. Each page of the Log will have a copy underneath it. The copy page will copy only the remedy information and will not copy patient specific information. The Log pages will provide space for recording 44 (forty-four) remedies dispensed. You agree to send the copy page together with a minimum of $400.00 (four hundred dollars) to the Pharmacy within one week of the date the page is completed. The Pharmacy agrees to restock your Kit by sending you the remedies listed on the Log copy page as dispensed.

The Pharmacy retains the right to inventory the Kit for business purposes twice yearly. The Pharmacy representative will contact your office two weeks prior to the inventory in order to arrange a mutually convenient time for inventory.

There are no restrictions by the Pharmacy on your right to select the appropriate medication for your patient in terms of manufacturer, remedy, potency, quantity or any other characteristic of the medicine your patient needs.

This written contract is the sole agreement between you and the Pharmacy regarding the Kit, there are no other agreements either written or oral regarding this contract.

Physician Responsibility

The Pharmacy has packaged the remedies in the Kit in patient unit-of-use containers. In order to be in full compliance with all laws regarding drug distribution you agree to provide the remedies in their original containers only, to your patients only, for the conditions for which you are treating them. You agree that the Pharmacy is not responsible in any way for maintaining your office in compliance with state law regarding physician dispensing and that the Log book is meant to assist you in maintaining compliance but will not guarantee compliance.

Contract Cancellation

You may cancel the contract with thirty day's notice provided you return the Kit and all unused remedies and pay the cost of any remedies dispensed which have not been restocked.

Pharmacy:

If the Kit is not being used or reordering is not occurring according to use, the Pharmacy retains the right to cancel the contract and reclaim the Kit at the Pharmacy's expense. Upon cancellation of the contract the Pharmacy also retains the right to collect all completed and partially completed copy pages of the Log.  You will be responsible as agreed above to provide a minimum of $400.00 per completed page and a prorated amount for any partially completed pages. In the event the Kit is not being used in accordance with the terms of this contract, the Pharmacy will perform an accounting and you will be responsible for any difference in the initial order and the reclaimed, intact, unopened products at the rate of $400.00 (four hundred dollars) per 44 remedies difference.

You agree to inform the Pharmacy if you change the location of your practice.

For Hahnemann Laboratories:

Your Name:______________________________________________

Signature:________________________________________________

Date:___________  Place:__________

Your Office Address:_______________________________________

Office Phone Number: (_____) ___________