I accept, understand, and agree to the following: I am
freely seeking medical consultation via the Internet and
I am aware that the physician reviewing my medical history
will not have the opportunity to conduct a personalized
in-person physical examination;
I am soliciting this site because I am seeking a specific
prescription medication to treat an already-identified
medical or cosmetic condition;
I understand that my "Medical History Questionnaire"
will be reviewed by a physician who is licensed in the
U.S. I acknowledge and agree that I, under no undue duress,
initiated contact with Prescription-Medication-Rx.com. I am aware that my
prescribing physician may be located in another state
or country other than my own and that said physician may
NOT be licensed to practice medicine in my state of residence
(referred to as the ("Consulting Physician");
I AGREE THAT ALL ON-LINE MEDICAL CONSULTATIONS, DIAGNOSES,
AND TREATMENTS WILL BE DEEMED TO HAVE OCCURRED IN THE
STATE WHERE THE PHYSICIAN IS "PHYSICALLY" LOCATED AND
LICENSED TO PRACTICE MEDICINE.
I am under the care of a primary care physician and I
do not consider the Consulting Physician to be my primary
care physician (unless I visit said physician for an in-person
personal doctor/patient consultation). I will not rely
on or substitute the advice given by the Consulting Physician
should it contradict the advice given to me by my primary
care physician;
I will not make a claim that the Consulting Physician
acted unprofessionally or below the standard of care solely
because the physician did not personally perform a physical
examination on me;
The Consulting Physician reviewing my "Medical History
Questionnaire" will make a decision based upon my honest
responses in making his or her decision regarding my request.
I understand each question I answered on the questionnaire
was responded to truthfully, accurately and completely.
I also understand that failure on my part to provide truthful,
accurate and complete information to the Consulting Physician
could cause him or her to unknowingly make an inappropriate
treatment decision affecting my physical or mental health.
To prevent this occurrence, I acknowledge that it is of
utmost importance that I am truthful when answering the
questions asked in the "Medical History Questionnaire";
Before taking any medication prescribed, I will ensure
that I have completed the following: accurately and honestly
completed a comprehensive physical examination by my primary
care physician; that I received a copy of the written
report of said examination, and that I have identified
my responses to the "Medical History Questionnaire" any
findings from my physical examination that are not within
the accepted average range;
Prescription-Medication-Rx.com does not practice medicine. I understand
that Prescription-Medication-Rx.com is a Management Service Organization
that received my request for a physician consultation
and, in turn, directs that request to a qualified independent
physician for review and response. The physician who reviews
my medical history and who makes the medical determination
as to whether or not I receive the medication I am seeking
is solely an independent contractor of Prescription-Medication-Rx.com and
is not an agent or employee of Prescription-Medication-Rx.com or its affiliates.
Prescription-Medication-Rx.com does not direct, control or influence the
treatment decisions made by the Consulting Physician with
respect to my care and/or my request from Prescription-Medication-Rx.com
is not liable for any negligent act or omission of the
Consulting Physician;
I understand that my medical record becomes the property
of the Consulting Physician or Prescription-Medication-Rx.com, and that,
in addition, Prescription-Medication-Rx.com will have continuing access to
and the right to copy and retain any and all portions
of my medical record;
I am over 18 years of age;
I am soliciting this site to determine whether or not
I fit the criteria for certain prescription medications.
I am not currently seeing my regular primary care physician
at this time because: a) this site is more convenient,
b) for other personal reasons;
I agree that any dispute arising out of or related to
the provision of services by the Consulting Physician,
by Prescription-Medication-Rx.com, its affiliates, or their employees, partners
and agents, shall be subject to mandatory mediation. Should
mediation fail to resolve the disputable issue(s), said
dispute shall be subject to final and binding arbitration,
as set forth in the United States Arbitration Act.
In accordance with the United States Arbitration Act,
I agree that any dispute arising out of or related to
the provision of services by the Consulting Physician,
by Prescription-Medication-Rx.com, its affiliates, or their employees, partners
and agents, shall be subject to final and binding arbitration
exclusively through the Procedures of the American Arbitration
Association. I understand that this agreement is voluntary
and that it is binding to any individual or entity claiming
by or through me or on my behalf; and I chose this site
on my own accord from several Internet options;
Any mediation, arbitration, administrative proceeding,
complaint, court proceeding, or other proceeding pertaining
in any way to this site must be held in the County of
Nevada, City Grass Valley, and in no other forum in any
other place. This Informed Consent expressly includes
knowing consent to transfer the venue of any dispute of
any kind to the above city and county for resolution.
I hereby release Prescription-Medication-Rx.com and the Consulting Physician
from all claims that the Consulting Physician acted unprofessionally
or below the standard of care solely because he/she did
not perform a physical examination on me.
This release includes, but is not limited to, my agreeing
to the following:
I have truthfully answered all of the questions and have
provided complete and accurate answers to the questions.
I further agree to make the Prescription-Medication-Rx.com physicians aware
of any changes in my medical condition in the event I
revisit this site to obtain more or different medication;
I am aware of potential side effects associated with
this medication. I personally accept all risks involved
in taking medication and will not seek any indemnification,
any damages of any kind, or any other liability from Prescription-Medication-Rx.com,
its parent, subsidiaries, affiliates, contractors, or
partners, if I experience any of the side effects;
I understand that no doctor, nurse, or administrative
personnel can guarantee that the prescription medicines
I am requesting will provide the results I seek;
It is my responsibility to have an annual physical examination,
including any suggested laboratory tests, to ensure that
I do not have a condition which will make my taking this
medication inappropriate or dangerous;
I have consulted with my physician and/or pharmacist
and am not currently taking any medications or combination
of medications that will make the medication I am requesting
inadvisable to take (contraindicated); and, I will notify
my primary care physician that I am taking the medication
that I requested so that he/she may advise me as to whether
or not I should continue or discontinue its use.
This document also serves as my informed consent to allow
Prescription-Medication-Rx.com access to any of my medical information, including
all medical data contained in the "Medical Records Questionnaire"
including, but not limited to, any health information
regarding HIV, mental health, alcohol, drug or substance
abuse conditions or treatments ("Medical Information").
I hereby authorize my Physician to release or disclose
to Prescription-Medication-Rx.com any and all Medical Information. I accept
that, with the exception for action formerly taken with
regard to this authorization, I can void this authorization
at any time by providing notices to Prescription-Medication-Rx.com or to
the Consulting Physician. This consent does not give Prescription-Medication-Rx.com,
its parent or sister companies, the right to sell my name
or information to any third party.
In consideration of Prescription-Medication-Rx.com's undertaking to render
the undersigned patient any administrative or any other
services relating in any way to this agreement, or Prescription-Medication-Rx.com
disclosing information or methods of treatment to patient
(either of which are deemed sufficient consideration for
this agreement) then, in the event any court determines
that the undersigned patient sought medical treatment
or medical prescriptions through Prescription-Medication-Rx.com for the possible
or apparent purpose, directly or indirectly, of deception,
assisting any investigation, or rendering of any type
of assistance to, or disclosing of any information pertaining
to Prescription-Medication-Rx.com, its procedures, officers, directors, or
medical protocols, to any news organization, possible
or actual competitor, any type of governmental agency,
any investigator or any party for possible or apparent
purposes of securing any information, confidential or
otherwise, about Prescription-Medication-Rx.com, its officers, directors,
shareholders, affiliates, banking relationships, contractors,
medical laboratories, contracting physicians, medical
protocols, sources of pharmaceuticals, proprietary medical
treatment protocols or Prescription-Medication-Rx.com's system of pharmaceuticals
procurement and dispensing, then the undersigned patient
knowingly, expressly and irrevocably consents to a judgment
in favor of Prescription-Medication-Rx.com, its officers, or any party proceeding
under the authority of this instrument, of liquidated
damages, jointly and severally against the undersigned
patient, as well as any express or apparent principle
(including patients employer) as an authorized or apparent
agent of his/her principle or employer, in the amount
of Three Million Dollars ($3,000,000.00), which liquidated
damage amount is hereby accepted by the undersigned as
a reasonable amount for engaging in such acts of deception
and because they are difficult to ascertain. The undersigned
patient engaged in such deception or any of the above
described acts, agrees on behalf of himself and his/her
principle, to pay all reasonable attorneys fees and
costs incurred by any person or entity seeking to enforce
this agreement. This agreement represents the complete
and entire agreement between the parties to it.
I understand that all prescription medications purchased
cannot be refunded.
ALL INFORMATION, ITEMS, AND SERVICES CONTAINED ON THIS
WEB SITE ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY
KIND, EXPRESSED OR IMPLIED.
IN USING THIS WEB SITE, I UNDERSTAND AND AGREE; (A) THAT
Prescription-Medication-Rx.com IS NOT RESPONSIBLE FOR THE NEGLIGENT OR INTENTIONAL
ACTS OR OMISSIONS OF ANY HEALTH CARE PROVIDER OR SUPPLIER
THAT I MAY BE LINKED WITH OR FOR ANY ACTION OR INACTION
TAKEN BY ME IN RELIANCE UPON THE INFORMATION COMMUNICATED
TO ME VIA THIS WEB SITE; (B) THAT THE TOTAL LIABILITY
OF Prescription-Medication-Rx.com AND ITS AFFILIATES, IF ANY, ARISING FROM
OR RELATED TO INTERACTIONS I HAVE WITH OR THROUGH THIS
WEB SITE (WHETHER THE CLAIM IS CONTRACT, TORT, WARRANTY,
NEGLIGENCE, MALPRACTICE, FRAUD, OR OTHERWISE) IS LIMITED
TO THE PURCHASE PRICE OF ANY PRODUCTS IN ANY RELEVANT
TRANSACTION AND (C) THAT Prescription-Medication-Rx.com SHALL NOT BE LIABLE
FOR ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL,
OR PUNITIVE DAMAGES.
IN ACCORDANCE WITH THE ABOVE UNDERSTANDING, I AGREE TO
RELEASE Prescription-Medication-Rx.com, THEIR EMPLOYEES, AGENTS, CORPORATE
AFFILIATES AND RELATED PARTIES FROM ANY AND ALL LIABILITY
ASSOCIATED WITH OR ARISING FROM THE PHYSICIAN CONSULTATION
OR FROM THE MEDICAL, PHYSICAL, BEHAVIORAL OR OTHER EFFECTS
OF ANY MEDICATION THAT MAY BE ORDERED, PRESCRIBED OR PURCHASED
AS A RESULT OF THE PHYSICIAN CONSULTATION.
IF ANY PROVISION OF THIS ABOVE AGREEMENT IS HELD TO BE
VOID, UNENFORCEABLE OR ILLEGAL, THEN I AGREE THAT THE
AGREEMENT WILL BE CHANGED OR LIMITED ONLY TO THE EXTENT
NECESSARY TO ENABLE THE REMAINING PROVISIONS TO BE OF
FULL FORCE AND EFFECT.
