I hereby state that I am an adult of 18 years of age or older, I am responsive of any possible side effects. And I hereby agree to answer truthfully all of the questions on a medical questionnaire given at your website.
I understand that no doctor can promise that medications, even if prescribed, will provide the results I seek. I acknowledge that no guarantees have been made to me as to the results as there is no known medical treatment that gives 100% fulfillment to everyone, nor are there any guarantees against unfavorable results, risks or problems.
I further acknowledge that if I am prescribed medication, I have full information that no physician, nurse or medical personnel can forecast as to whether I would or would not have any adverse effects. I understand that all possible risks and/or complications do not require to be explained to me, nor do I consider this practical or even possible because risks and complications may take place anytime. I hereby release any associated prescribing physicians from any and all legal responsibility whatsoever with any adverse effect I may suffer from.
I fully understand that it is my duty to have a routine physical examination to make sure that I have no disease(s) that might make certain medications inappropriate for my condition. I further agree that I have consulted with my physician and/or pharmacist and hereby merit that I do not have any conditions or I am not taking any medications that would make a contraindication. I further agree to instantaneously notify any doctor whose present care I am under that I have selected to take a certain medication.
I hereby surrender a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians. I understand that an on-line medical consultation will NOT embrace an actual physical exam. I understand that it is my responsibility to have routine physical examinations to ensure that I have no illness nor contract any conditions that may make taking a medication contraindicated. I further agree to directly notify any doctor whose present care I am under that I have chosen to take a medicine.
Patient Responsibility agreement
By submitting this consultation form I confirm as if under oath and state truthfully that:
I am an 18 years old capable adult at least 18 years.
I am allowed by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic reasons and release from any liability in case if current operation is considered to be corrupt.
I, the patient, have had a recent satisfactory and adequate physical examination and medical history evaluation by a local physician who is accessible and whom I agree to contact for any necessary local follow-up care and intervention, in case if I have any difficulties, possible complications, or questions. I know also that I may contact the prescribing doctor and the dispensing pharmacy.
I have been fully informed by suitably trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may ask for, I have studied written or internet legal materials on these drugs including the websites and links that offer in-depth material.
I also affirm that I have earlier safely used the medication(s) I may request, under a physician’s supervision, or I have been advised by my examining physician that the use of the medication(s) is not contraindicated for me and is suitable for my personal therapeutic and medical needs.
I am requesting the prescription medication(s) solely for my own personal therapeutic and medical requirements, and will not distribute any of the medication to others.
