By submitting this order form, I hereby certify that:
- I am at least 21 years of age.
- I am permitted by law in my locale to receive the drug I am requesting.
- I, the patient, have had a recent physical examination and medical history evaluation by a physician who is available for any necessary local follow-up care and intervention.
- I have been fully informed and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request,
- I safely used the drug I may request under a physician's supervision or been advised be an examining physician that the use of the drug is not contraindicated for me and is appropriate for my therapeutic and medical needs.
- I am requesting the prescription drug solely for my therapeutic and medical needs, and will not distribute the said drug to others.
- I am requesting that a licensed prescriber act only in an adjunct capacity to my local physician, not replace my local physician, when reviewing my request, and if authorizing the prescription drug(s) for dispensing by the virtual clinic's associated Online Pharmacy.
- I am seeking the prescription(s) for the necessary supply of drug, 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 related to the use of the requested drug arise.
- I am allowed by law to use the credit card that will be used if my request is approved and processed.
- I have and will answer all questions truthfully, for my safety, just as I would in my local physician's office and care.
- I realize there are risks, as well as benefits, to any drug, even OTC drugs, and having been informed of possible effects, I consent to treatment as I may request and take full and complete responsibility.
I understand that this online store is not a Online Pharmacy, but an online escrow service that contracts with reputable, fully-licensed pharmacies that dispense drugs to customers placing orders through its online escrow service system, and that this store acts as a drug broker between myself (the buyer) and the licensed Online Pharmacy (the seller).
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