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By
submitting this consultation form I affirm as if under oath and
state truthfully that:
- I am a competent adult
at least 18 years of age.
- I am permitted by law in my locale to
receive the medication(s) I am requesting for my personal medical
and therapeutic purposes.
- 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 I have any difficulties, possible complications, or questions.
I know also that I may contact the prescribing physician and the
dispensing pharmacy, and I will keep those toll free numbers available.
- 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 materials on these drugs including the web sites
and links that offer in-depth material.
- I also affirm that I have
previously safely used the medication(s) I may request, under a
physician's supervision, or I 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.
- 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.
- I am requesting that a U.S. licensed
prescriber act only in an adjunct capacity to my local physician,
and 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.
- 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.
- 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.
-I agree not to take any
over-the-counter medicines without approval from my pharmacist.
- 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.
- I am allowed by
law to use the credit card that will be used if my request is
approved and processed.
- 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.
- 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
STATEMENT©
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