Patient Responsibility and Compliance Agreement
By continuing with this consultation I am affirming and truthfully stating, as if I was under oath, the following:
1. I am an adult of sound mind and judgement and at least 18 years of age.
2. I am entirely permitted by the laws in my residing country to receive the medication / treatment that I am requesting, for my personal use.
3. I, the patient, have recently undergone an examination with a local doctor who has evaluated my current condition and past medical history and deemed this to be to a satisfactory level. I can also affirm that my local doctor is a registered medical practitioner and is available for a further consultation if the need arises and I agree to immediately contact my doctor for any necessary check-up, care or intervention in the event that I should experience any side effects or complications or have any questions in respect of the medication(s). The prescribing doctor and the dispensing pharmacy may also be contacted and I will email them accordingly to arrange for the prescribing doctor or the dispensing pharmacy to call me back, if the need arises. I accept that the prescribing doctor or a appointed representative may contact me for any reason whatsoever even if I have not requested him to do so.
4. The medication(s) and prescription(s) that I am requesting are entirely for my own personal medical needs only. The medication(s) and prescription(s) requested are required for my condition and will not be used to sell onto any third party or used to stockpile an excess of medication beyond what an adequate supply.
5. I confirm that I have been informed by an appropriately trained health care professional and fully understand the benefits, possible side effects and risks of the prescription treatment(s) I may request, I have also studied written or internet materials on these medications including various links and websites that offer in-depth material on the subject.
6. I also affirm that I may on previous occasions have used the medication(s) I am requesting under a Doctor's supervision and that their use was safe and free from side effects. I also state that I have been advised by my local examining doctor that the use of the medication(s) is not contraindicated for me and is appropriate for my personal medical needs.
7. By completing this consultation and anything associated here forth, I am requesting that a registered UK or EU prescriber act only in an adjunct capacity to my local doctor. I do not wish for this registered prescriber to replace my local doctor. As a result I confirm that I am requesting that the registered prescriber considering my consultation issue the prescription for dispensing by the associated licensed pharmacy.
8. I agree to immediately contact a registered Doctor for any necessary medical intervention should a complication or side effect manifest whilst using the medication(s) or at any time thereafter. Before taking any other new medicines, I agree to first obtaining approval from a registered medical practitioner or pharmacist and take full responsibility for doing so.
9. I affirm that all the questions answered in the consultation have been done so truthfully and to the best of my knowledge, in the same way I would answer a ‘face-to-face’ consultation with my local doctor. I understand that full disclosure is essential in maintaining my personal safety for the requested medication(s) I will without fail adhere to this condition of disclosure at all times.
10. As a further affirmation of the aforementioned point, I have openly disclosed all information regarding my medical history that may be relevant. I have no way omitted or misrepresented any information during the consultation process.
11. I fully understand that there are risks as well as benefits associated with and to the use of any medication or treatment(s). I have not been forced to undergo treatments and or medications that I have or may request and do so out of my own free will.
12. I agree to monitor my blood pressure and will do so at least once every 7 (SEVEN) days. I agree to stop taking the medication immediately if my blood pressure is higher than 140/90 (if the top number is greater than 140 or the bottom number is greater than 90).
13. I am permitted by law to use the credit card and any other payment card used to purchase the medication(s) or treatment, if my request is approved.
14. I agree that by proceeding with this request for the chosen treatment or medication(s), I am voluntarily agreeing to all of the above mentioned points. I understand that by continuing, I irrevocably bind myself to the terms and conditions contained herein.