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I am freely
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the physician reviewing my medical history will not have the opportunity
to conduct a personalized in-person physical examination;
I am soliciting
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I understand
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by a physician who is licensed in the U.S. I acknowledge and agree
that I, under no undue duress, initiated contact with www.2-buy-viagra-cheap-online.com
and / or their actual suppliers / shippers, with whom my order shall
be placed. I am aware that my prescribing physician may be located
in another state or country other than my own and that said physician
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(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;
www.2-buy-viagra-cheap-online.com
do not practice medicine. I understand that www.2-buy-viagra-cheap-online.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 www.2-buy-viagra-cheap-online.com
and is not an agent or employee of www.2-buy-viagra-cheap-online.com
or its suppliers / affiliates. www.2-buy-viagra-cheap-online.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 www.2-buy-viagra-cheap-online.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 www.2-buy-viagra-cheap-online.com's suppliers, and that, in
addition, www.2-buy-viagra-cheap-online.com and their agents /
suppliers will have continuing access to and the right to copy and
retain any and all portions of my medical record;
I am 21
years or over 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 www.2-buy-viagra-cheap-online.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 www.2-buy-viagra-cheap-online.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
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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 Cobb, City of Marietta, 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 www.2-buy-viagra-cheap-online.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
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I have truthfully
answered all of the questions and have provided complete and accurate
answers to the questions. I further agree to make www.2-buy-viagra-cheap-online.com's
agent's / supplier's 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 www.2-buy-viagra-cheap-online.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 www.2-buy-viagra-cheap-online.com's
chosen supplier(s) 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 www.2-buy-viagra-cheap-online.com's
supplier(s) 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
www.2-buy-viagra-cheap-online.com's supplier(s) or to the Consulting
Physician. This consent does not give www.2-buy-viagra-cheap-online.com,
its suppliers or parent or sister companies, the right to sell my
name or information to any third party.
In consideration
of www.2-buy-viagra-cheap-online.com and/or their supplier's undertaking
to render the undersigned patient any administrative or any other
services relating in any way to this agreement, or www.2-buy-viagra-cheap-online.com
and / or their supplier(s) 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
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through www.2-buy-viagra-cheap-online.com and / or their supplier(s)
for the possible or apparent purpose, directly or indirectly, of
deception, assisting any investigation, or rendering of any type
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procedures, officers, directors, or medical protocols, to any news
organization, possible or actual competitor, any type of governmental
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contracting physicians, medical protocols, sources of pharmaceuticals,
proprietary medical treatment protocols or www.2-buy-viagra-cheap-online.com
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and severally against the undersigned patient, as well as any express
or apparent principle (including patients employer) as an
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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
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AND/ OR IT'S SUPPLIER(S) ARE 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
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LLC 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
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IN ACCORDANCE
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AND / OR THEIR SUPPLIER(S), 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.
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