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 certify that I am 21 years of age or older.
I am permitted by law in my locale to receive the medication(s) I am requesting.
I have been fully informed and understand the risks, benefits, and possible side effects of the prescription drug(s) I am requesting.
I certify that I will use this prescription medication for, and only for, the prescribed use, and that I will not use it in conjunction with any illegal substance.
Should I experience any problems, whatsoever, I promise to contact immediately the prescribing physician, as well as my local physician and discontinue taking this medication, or seek treatment at an appropriate medical facility. I will continue to follow-up with the online prescribing practitioner and my general physician at least once every twelve months, or more often as instructed, for physical exams and laboratory studies.
CONSENT TO MEDICAL CARE I hereby release Secure Medical, Inc. and its employees, its contracted physicians, dispensing pharmacies, and all related persons from any and all liability whatsoever associated or connected with my participation in ordering medications to treat my illness and ailments.
The manufacturer and the physician affiliates at Secure Medical, Inc. recommend a physical examination and a blood work up by a doctor before taking any medication. I understand that an on-line medical consultation will not include a physical examination. I hereby waive a physical examination at this time and agree to obtain a follow-up medical examination before taking any medication.
I certify that I have and will answer all the questions truthfully? I also certify that I have completed this application with the purpose of seeking the service of our affiliated physicians and that they will be relying on the truth and accuracy of my answers in determining whether I should have this medication supplied to me.
LOCAL PHYSICIAN CONSENT I understand that the medication above is a prescription medication and therefore, the pharmacy is unable to accept returns or issue refunds for any prescription medication.
I attest to and affirm that my local physician (MD or DO), is fully Aware of my intent to take this prescription medication. Furthermore my physician Approves of me taking this prescription and is aware of All medicines that I am taking and plan to take. I understand that I Must Not take this prescription unless I have consulted with a local licensed physician (MD or DO) who has fully evaluated my condition and Approves of my use of this medicine.
I will use this medication Only and Exactly as directed by my local licensed physician. Should I experience any problems, whatsoever, I promise to immediately contact the prescribing physician, as well as my local physician and discontinue taking this medication, or seek treatment at an appropriate medical facility. In the event of experiencing significant adverse medical conditions, or in the case of a medical emergency, I will contact a local Physician or hospital for immediate care and not rely on my online Physician for emergency medical care.
I will continue to follow-up with the online prescribing practitioner and my general physician at least once every 24 months, or more often as instructed, for physical exams and laboratory studies.
CONSENT TO ACCESS MEDICAL RECORDS I hereby grant the physician affiliates of Secure Medical, Inc. access to my medical records, if they need to review them in order to assure that they can provide me with quality health care. In order to comply with many state laws and optimum quality medical practice I authorize the physician affiliated with Secure Medical, Inc. to access my medical records if they require information contained in them to evaluate my medical fitness for any medication. I agree to be contacted first by the physician affiliates of Secure Medical, Inc. before they access my medical records.
I certify that I am allowed by law to use the credit card that will be used if my request is approved. I understand that my credit card will be billed for this process.
I certify that I am requesting this prescription medication to treat a medical condition and not for recreation or other illicit purposes.