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- 1. I hereby authorize and allow pillinternet.com and any of its physicians, employees, associates, and contractors to perform and undertake an on-line medical consultation and evaluation of me for a potential patient for medications. I hereby release pillinternet.com online physicians and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my medical Consultation and/or use of prescribed medications.
- 2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects. And I hereby agree to answer truthfully all of the questions on medical questionnaire provided at pillinternet.com.
- 3. I understand that no doctor can guarantee 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% satisfaction to everyone, nor are there any guarantees against unfavorable results, risks or complications.
- 4. I further acknowledge that if I am prescribed medication, I have full knowledge that no physician, nurse or medical personnel can predict as whether I would or would not have any adverse effects since every individual has a unique biological/chemical make-up. I understand that all possible risks and/or complications do not need to be explained to me, nor do I consider this practical or even possible because risks and complications may occur that have never been recorded before. I hereby release any associated prescribing physicians from any and all liability whatsoever with any adverse effect I may suffer from.
- 5. I am participating in this online consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of these medications. I acknowledge and agree that I initiated this contact, and I agree that all on-line medical consultations and treatments will be deemed to have occurred in the state or country where the physician is physically located and licensed to practice medicine which may be in another state or country from my own.
- 6. I fully understand that it is my responsibility to have routine physical examination to ensure 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 warrant that I do not have any conditions or I am not taking any medications that would make a contraindication. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take a certain medication.
- 7. I understand that if I have failed in any way to provide the online consulting physician with my complete and accurate medical history or if I fail to notify the online consulting physician pillinternet.com of any changes in the future, then I can not hold them or its physicians responsible for any adverse effects I may suffer and I am solely responsible for any adverse effects I may suffer from taking or continuing to take medications or from participating in this program.
- 8. I hereby waive 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 include an actual physical exam. I understand that it is my responsibility to have routine physical examinations to ensure that I have no diseases nor contract any conditions that may make taking A medication contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take a medication.
Patient Responsibility Agreement
By submitting this consultation form I affirm as if under oath and state truthfully that:
- 1. I am a competent adult at least 18 years of age.
- 2. I am permitted by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic purposes and release pillinternet.com from any liability in case if current operation is considered to be corrupt.
- 3. I, the patient, have had a recent satisfactory and sufficient physical examination and medical history evaluation by a local physician who is available 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 physician and the dispensing pharmacy.
- 4. I have been fully informed by appropriately trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request, I have studied written or internet legal materials on these drugs including the websites and links that offer in-depth material.
- 5. I also affirm that I have previously 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 appropriate for my personal therapeutic and medical needs.
- 6. I am requesting the prescription medication(s) solely for my own personal therapeutic and medical needs, and will not distribute any of the medication to others.
- 7. I am requesting that possibly a non U.S. licensed prescriber act only in an adjunct capacity to my local physician, and does not replace my local physician, when reviewing my request. I further request the prescriber to authorize the prescription drug(s) for dispensing by the clinic's associated licensed pharmacy.
- 8. I affirm that I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand.
- 9. I will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication.
- 10. I agree not to take any over-the-counter medicines without approval from my pharmacist.
- 11. I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately.
- 12. I am allowed by law to use the credit card that will be used if my order is approved and processed.
- 13. I affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local physician's office and under that physician's care, I have fully and completely disclosed any and all information concerning my health and medical history that my possibly be relevant to my request for this medication.
- 14. I realize there are risks as well as benefits to any medication, even OTC drugs. I have been fully informed of the possible effects, risks, and benefits of this medication. I agree that I have been previously and recently examined sufficiently as to physical and medical condition, and I have been provided sufficient information and adequately understand, the same as or more than if this consultation had taken place with my local physician in a physical office setting.
Patient Responsibility Agreement
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We can request your personal information in order to process the purchase with our resource. We collect visitor's contact information (such as email address). Contact information from the order form is used to send orders and information about our company to our customers. Users may choose not to receive future mailings. Financial information that is collected by the banking system is used to bill the user for products and services. Medical information is used by our medical staff to approve or decline orders for specific medications and ensure that you have the right product.
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