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Patient Affirmation Agreement The Genuine Pills

By submitting this medical consultation form, I affirm, as if under oath, and state truthfully that:

1.  I am allowed by law in my country and region to receive the medication(s) I am requesting for my personal medical and therapeutic purposes.

2.  I am 18 years or above 18 years and a competent adult to undertake this medical consultation program.

3.    I, the patient, have had a recent satisfactory and sound physical examination and medical history evaluation by a local physician who is available and with whom I agree to contact for appropriate follow-up care and intervention, should I experience any complications, adverse effects, difficulties or questions. I am aware that I may need to contact the prescribing physician and the dispensing pharmacy.

4.    I have been appropriately and fully informed by trained medical and/or health care professional and understand the benefits, risks and possible complications, side effects of the prescribed medication that I may request and that I have also personally studied printed or internet materials related to such medication including the websites and links that offer such information.

5.    I also affirm that I have safely and previsously used the medication(s) I may request, along with a doctor’s supervision, or had been advised by my examining physician that the use of such medication(s) is not contraindicated for me and is appropriate for my medical and therapeutic needs.

6.    I am availing the prescription medication(s) only for my own personal medical and therapeutic needs, and will not, nor my intention to distribute any of the prescribed medication to others.

7.    I understand that a licensed prescriber acts only in a complementary and adjunct capacity to my personal physician, and does not imply the replacement of my local physician, when evaluating or reviewing my request. I hereby authorize the prescriber to cause the prescription drug(s) for dispensing by The Genuine Pills.

8.    I declare that I am seeking the prescribed drugs for a necessary supply for my medication NOT to accumulate beyond an already adequate supply on hand.

9.    I will immediately contact my physician or seek promptly the help of competent medical professionals should medical intervention be necessary should a complication or contraindication arise as a result related to the use of the requested medication.

10.  I agree not to receive any over-the-counter drugs without the approval of my pharmacist.

11.  I agree to check my blood pressure 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 discontinue this medication immediately. 12.  I am permitted by law to use the credit card for this program should my request medication is approved and processed.

13.  I declare and affirm that I have truthfully answered and will answer all questions honestly, for my own safety, just as I would in my local physician's office. I declare that I have fully and accurately disclosed any and all information pertaining my health condition and medical history that may possibly be relevant or useful to my request for this medication.

14.  I am aware of the risks as well as benefits to any medication, even over-the-counter drugs. I have been fully informed of the benefits as well as the potential side effects and health risks of this medication. I declare that I have been previously and recently examined sufficiently as to my medical and physical condition and that and I have been provided information satisfactorily and adequately understood the same as if or more than this consultation had taken place with my personal physician in a physical office setting. 

 
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