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 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;
Medication-Rx.com does not practice medicine. I understand
that 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 Medication-Rx.com and is not
an agent or employee of Medication-Rx.com or its affiliates.
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 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 Medication-Rx.com,
and that, in addition, 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 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 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 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 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 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 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 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 Medication-Rx.com or to the Consulting Physician. This
consent does not give Medication-Rx.com, its parent or
sister companies, the right to sell my name or information
to any third party.
In consideration of Medication-Rx.com's undertaking to
render the undersigned patient any administrative
or any other services relating in any way to this
agreement, or 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 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 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 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 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 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 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 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 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 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.
