Informed consent

I accept, understand, and agree to the

I am freely of my own will seeking medical
consultation via the Internet and I am aware that the Consulting
Physician reviewing my information may not conduct a personalized
in-person physical examination. I consider the consultation by way
of the internet to be an appropriate and adequate means of
evaluating my condition. A licensed U.S. Physician will review my
medical information. I will not make a claim that the Consulting
Physician acted unprofessionally, improperly, or below the standard
of care solely because the physician did not personally perform a
physical examination on me;

I understand that my medical evaluations, recommendations,
diagnoses, and treatments will be reviewed by a physician who is
licensed in the U.S. I acknowledge and agree that I, under no
duress, initiated contact with I am aware that my
prescribing physician may be located in another state other than my
own and that the Consulting Physician may NOT be licensed to
practice medicine in my state of residence;

This consultation and treatment recommendation constitutes a
legitimate physician-patient relationship in the state where the
Consulting Physician is licensed to practice medicine;

I acknowledge that it is essential that I provide truthful
answers to the questions on the Medical Evaluation Form and through
out this site. The Consulting Physician evaluating my medical
information will make a decision based upon my honest responses in
making a decision regarding my request. I take a solemn oath to
provide truthful, accurate and complete information to the questions
on the questionnaire. I further understand that failure on my part
to provide truthful, accurate and complete information in detail to
the Consulting Physician could cause him/her or the pharmacist to
make an inappropriate treatment decision that could adversely affect
my physical or mental health;

I am under the care of a primary care physician and do not
consider the Consulting Physician to be my primary care physician. I
will not rely on or substitute the advice given by the Consulting
Physician should it be contrary to or in conflict with the advice
given to me by my primary care physician. Before taking any
medication prescribed, I will ensure that I have completed a
comprehensive physical examination by my primary care physician;

I further agree to make and my Consulting
Physician and pharmacist aware of any changes in my medical
condition or medications;

I am aware of the risks, benefits, alternatives to, and potential
side effects of this medication and have had the opportunity to ask
any questions that I may have had regarding my health situation
and/or treatment;

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 use of this medication
inappropriate or dangerous;

I have consulted with my physician and/or pharmacist and am not
currently taking any medication or combination of medications that
will make the medication I am requesting inadvisable or

It is my responsibility to notify my primary care physician that
I am taking the medication that I requested so that they may advise
me as to whether or not I should continue or discontinue its use;

MedscriptsLLC does not practice medicine. I understand that
Medscripts LLC 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
Medscripts LLC and is not an agent or employee of Medscripts LLC or
its affiliates. Medscripts LLC does not direct, control or influence
the treatment decisions made by the Consulting Physician with
respect to my care and/or my request from Medscripts LLC is not
liable for any negligent act or omission of the Consulting

I understand that my medical record becomes the property of the
Consulting Physician or Medscripts LLC, and that, in addition,
Medscripts LLC will have continuing access to and the right to copy
and retain any and all portions of my medical record;

The undersigned acknowledges that it is illegal to attempt to
obtain a prescription medication for any reason by providing false
or misleading information or by any other means of deception;

In consideration of undertaking to render the
undersigned patient any administrative or any other services
relating in any way to this agreement, of
disclosing information or methods of treatment to patient (either of
which are deemed sufficient consideration for this agreement), in
the event any court determines that the undersigned patient sought
medical treatment or medical prescriptions through
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 its procedures, officers, directors, consultants,
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, its officers,
directors, shareholders, affiliates, banking relationships,
contractors, medical laboratories, Consulting Physicians, medical
protocols, sources of pharmaceuticals, or proprietary medical
treatment protocols, then the undersigned patient knowingly,
expressly and irrevocably consents to a judgment in favor of, 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 patient’s employer), as an authorized
or apparent agent of his/her principle or employer, in the amount of
six million dollars ($6,000,000), 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, if engaging in such deception or
any of the above described acts, agrees on behalf of himself and
his/her principle, to pay all reasonable attorney’s 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;

The undersigned also agrees that if the Consulting Physician
approves the patient for a requested prescription medication, then
the Medication and Prescription charges will be deemed to be earned
and will be immediately due and payable and not refundable. In the
case that the patient is denied the prescription medication
requested there would be no administrative fee

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