By submitting this consultation form, I affirm and certify that:
I am of sound mind and at least 21 years of age.
I am permitted by law in my locale to receive the medication(s) I am requesting for my personal use only.
I have recently undergone a complete physical examination and medical history evaluation by my own primary care physician who is available and whom I agree to contact for any necessary local follow-up care and intervention.
I have been fully informed by health care personnel and have studied written or internet materials on these drugs and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request.
I have previously used the medication(s) I may request safely, while under a physician's supervision, and/or I been advised by my examining physician that the use of the medication(s) is not contraindicated for me and is appropriate for my personal therapeutic and medical needs.
The medication I am requesting is solely for my own personal therapeutic and medical needs, and I agree not to distribute any of the medication(s) to others.
I am seeking the requested prescription(s) to have a necessary supply of medication on hand, and will not stock this medication beyond an adequate supply. I will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication.
I will not take any over-the-counter medicines without full disclosure to my pharmacist and primary care doctor of all medications that I am taking.
I am authorized by law to use the credit card that will be used if my request is approved and processed.
I realize there are risks as well as benefits to any medication, even OTC drugs. As such, I have been fully informed of the effects, risks, and benefits of this medication. I consent to treatment as I may request.