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 Online-Pharmacy-Scripts.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;
Online-Pharmacy-Scripts.com does not
practice medicine. I understand that Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.com and is
not an agent or employee of Online-Pharmacy-Scripts.com
or its affiliates. Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.com, and that, in addition,
Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.com or to the
Consulting Physician. This consent does not give
Online-Pharmacy-Scripts.com, its parent or sister
companies, the right to sell my name or information
to any third party.
In consideration of Online-Pharmacy-Scripts.com's
undertaking to render the undersigned patient any
administrative or any other services relating in
any way to this agreement, or Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.com,
its officers, directors, shareholders, affiliates,
banking relationships, contractors, medical laboratories,
contracting physicians, medical protocols, sources
of pharmaceuticals, proprietary medical treatment
protocols or Online-Pharmacy-Scripts.com's system
of pharmaceuticals procurement and dispensing, then
the undersigned patient knowingly, expressly and
irrevocably consents to a judgment in favor of Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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 Online-Pharmacy-Scripts.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.
