Patient Responsibility Form

• I am a competent adult at least 18 years of age.
• I am permitted by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic purposes.
• I, the patient, have had a recent satisfactory and sufficient physical examination and medical history evaluation by a local physician who is available and whom I agree to Contact Us for any necessary local follow-up care and intervention, in case I have any difficulties, possible complications, or questions. I know also that I may Contact Us the prescribing physician and the dispensing pharmacy, and I will keep those phone numbers available.
• I have been fully informed by appropriately trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request, I have studied written or internet materials on these drugs including the websites and links that offer in-depth material.
• I also affirm that I have previously safely used the medication(s) I may request, under a physician's supervision, 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.
• 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 am requesting that a U.S. licensed prescriber act only in an adjunct capacity to my local physician, and not replace my local physician, when reviewing my request. I further request the prescriber to authorize the prescription drug(s) for dispensing by an associated licensed pharmacy.
• I affirm that I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand.
• I will promptly Contact Us or a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication.
• I agree not to take any over-the-counter medicines without approval from my pharmacist.
• I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately.
• I am allowed by law to use the credit card that will be used if my request is approved and processed, and for associated physician review fee processing if my request is denied.
• I affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local physician's office and under that physician's care, I have fully and completely disclosed any and all information concerning my health and medical history that may possibly be relevant to my request for this medication.
• I realize there are risks as well as benefits to any medication, even OTC (over the counter) drugs. I have been fully informed of the effects, risks, and benefits of this medication. I agree that I have been previously and recently examined sufficiently as to physical and medical condition, and I have been provided sufficient information and adequately understand, the same as or more than if this consultation had taken place with my local physician in a physical office setting.