ACKNOWLEDGEMENT AND CONSENT BY PATIENT
In being of sound and disposing mind, I hereby acknowledge and accept
- I am above the age of eighteen (18) years, and have entered into a
contract with prescriptionpharmacy4u.com of my own free will, and that I did not act
under duress or undue influence.
- I am the authorized cardholder of the credit card used for payment of
the requested medication.
- In respect of my order for medicine:
I acknowledge and confirm that the medication shall be for my
exclusive personal use, and that I shall use it as directed. I shall not
pass it on to other persons, or be a party to reselling the medication.
I warrant that I have checked to ensure that the importation of
prescription drugs into my jurisdiction of residence by me does not
violate the laws of my jurisdiction or any jurisdiction at which I may
accept delivery of medication shipped to me as a consequence of my
I confirm that I have undergone a recent and satisfactory physical
examination by a doctor licensed to practice medicine in my jurisdiction
of residence (herein after called my 'Personal Healthcare
Practitioner'), I further confirm that my Personal Healthcare
Practitioner has diagnosed a certain medical condition, and I attest
that I am utilizing the services of prescriptionpharmacy4u.com only to obtain medication
for the identified medical condition. I agree to consult my Personal
Healthcare Practitioner in the event of difficulties, questions, or
complications. I acknowledge that I have previously used the
medication(s) that I may request with no ill effects, or I have been
advised by my Personal Healthcare Practitioner that the use of the
medication(s) is proper for my medical needs.
I confirm that the Medical Questionnaire contains my full and honest
medical history, and that I have answered the questions truthfully,
openly and honestly, and to the best of my knowledge.
I understand that in using the facilities of prescriptionpharmacy4u.com the contents
of my medical questionnaire, including my medical history becomes the
property of prescriptionpharmacy4u.com. I acknowledge that prescriptionpharmacy4u.com has the right to
store this information, place it at the continuing disposal of it's
staff, and any other persons involved in my treatment, and to continue
to copy, retain and use the said information and records relating to me.
I also understand that my Medical Questionnaire will be reviewed by a
prescribing physician. I am aware that this physician may or may not be
licensed to practice in the state where I am located at the time that I
submit my Medical Questionnaire. All medical decisions made by the
prescribing physician regarding my medication(s) and any treatment
prescribed will be deemed to have occurred in the state where the
physician is physically located.
I agree that any dispute arising between me and prescriptionpharmacy4u.com, its
agents, servants, staff, and/or health care professionals, and
affiliates in relation to the provision of services to me shall be
referred to mediation. If mediation should fail, I accept that the
points/issues in dispute may be referred to Arbitration along the
principles set out in the US Arbitration Act. The decision of the
Arbitrator (s) shall be final, and no appeal or review application shall
lie there from. This agreement is binding on me and/or any
agent/attorney suing on my behalf, and/or my heirs and executors.
Further regarding my use of the prescriptionpharmacy4u.com website and other
facilities, I warrant that I have used and shall always use these
facilities for the purpose only of seeking medical treatment, not for
stockpiling drugs to an already adequate supply.
Regarding my treatment, received through prescriptionpharmacy4u.com, I confirm that:
- I hereby specifically request that the pharmacist dispensing my order
DOES NOT substitute a generic in place of any brand medicine that I
- I fully accept, and understand that this may mean that I have been
charged more for the brand medicine than I would have been charged for
the equivalent generic (where available).
I understand and agree that:
- I shall seek information from my pharmacist and/or Personal
Healthcare Practitioner regarding the risks, benefits, and possible side
effects of my medication. I agree not to take any other prescription
medication or over-the-counter medicines without consulting with my
pharmacist who is aware of my use of all medications.
- I will use such medication under the strict supervision of my
Personal Healthcare Practitioner, whose advise shall take precedence
over that of, and shall not be supplanted by that of, any other health
professional involved in my care.
- I undertake to make contact promptly with my Personal Healthcare
Practitioner or any medical practitioner for any necessary emergency
intervention should a complication arise following my use of my
- I appreciate that there are always attendant risks to the use of any
medication. I understand that I must have regular physical examinations
and laboratory tests to ensure that it is safe for me to take the
medication. I accept all risks involved in taking the medication. I will
not seek any damages or any other liability from prescriptionpharmacy4u.com, its
affiliated companies, contractors, agents or principals, if any
side-effects occur as a result of my use of the medication.
- I appreciate that no health professional may guarantee that my
medication shall have the desired effects or will provide the results I
I agree to release prescriptionpharmacy4u.com, its employees, agents, principals,
corporate affiliates and all related parties from any liability arising
from my consumption of the medication and for medical, physical or
behavioral and other effects of any medication that I may take as a
consequence of my order.
I understand that prescriptionpharmacy4u.com is not engaged in the practice of
I understand that my Medical Questionnaire is the property of the
prescribing physician. I understand that prescriptionpharmacy4u.com, because it stores
and maintains my Medical Questionnaire, has access to my personal
information and health information. prescriptionpharmacy4u.com may use my personal and
on this website, which I have reviewed. I understand that, upon request,
I may review the information prescriptionpharmacy4u.com has collected about me and notify
prescriptionpharmacy4u.com of incorrect information.
I agree that if any court should find any part or provision of this
agreement to be void or unenforceable, the void or unenforceable part of
the agreement shall be excised from the whole agreement, the remainder
of which I accept shall remain binding on me, and of full force and
- prescriptionpharmacy4u.com shall not be liable for any acts or omissions of its
associated health professionals, and of my Personal Healthcare
Practitioner in advising me or communicating with me with regard to my
medication. I release prescriptionpharmacy4u.com from any and all claims related to
allegations that the prescribing physician acted below the standard of
reasonable medical care because he/she did not perform an in-person
- The total liability, if any, of prescriptionpharmacy4u.com related or arising from my
use of this website to purchase a medication is limited to the purchase
price of the medication purchased. In no instance shall prescriptionpharmacy4u.com be
liable for any direct, indirect, special, incidental, consequential, or
- I am aware that the prescribing physicians are not employed by
prescriptionpharmacy4u.com but are independent contractors to whom prescriptionpharmacy4u.com gives my
information for review. prescriptionpharmacy4u.com does not direct, control, or influence
the medical decisions made by the prescribing physicians with respect to
medication(s). I agree not to hold prescriptionpharmacy4u.com liable for any act or
omission, negligent or otherwise, of the prescribing physician.
- The prescribing physician will review my truthful history and will
decide whether or not to authorize a prescription based on an ongoing,
previously diagnosed medical condition and on that decision basis, the
prescribing physician shall, in no instance, be liable for any direct,
indirect, special, incidental, consequential, or punitive damages
resulting from that decision.