I accept, understand, and agree to the following:
I am freely seeking medical consultation via the Internet
and I am aware that the Physician reviewing my medical
history will not have the opportunity to conduct a personalized
in-person physical examination;
I am soliciting this site because I am seeking specific
drug information. I am also soliciting this site because
the site may offer the ability to secure 3rd party specific prescription
medication to treat an already-identified medical or cosmetic
condition;
I understand that my Medical History Questionnaire will
be reviewed by a Physician who is licensed in the U.S. I
acknowledge and agree that I, under no undue duress, initiated
contact with Allaboutdietdrugs.com. I am aware that my prescribing
Physician may be located in another state or country other
than my own and that said Physician may NOT be licensed to
practice medicine in my state of residence (referred to as
the ("Consulting Physician");
I AGREE THAT ALL ON-LINE MEDICAL CONSULTATIONS, DIAGNOSES,
AND TREATMENTS WILL BE DEEMED TO HAVE OCCURRED IN THE STATE
WHERE THE PHYSICIAN IS PHYSICALLY LOCATED AND LICENSED TO
PRACTICE MEDICINE.
I am under the care of a primary care Physician and I do
not consider the Consulting Physician to be my primary care
Physician (unless I visit said Physician for an in-person
personal doctor/patient consultation). I will not rely on
or substitute the advice given by the Consulting Physician
should it contradict the advice given to me by my primary
care Physician;
I will not make a claim that the Consulting Physician acted
unprofessionally or below the standard of care solely because
the Physician did not personally perform a physical examination
on me;
The Consulting Physician reviewing my Medical History Questionnaire
will make a decision based upon my honest responses in making
his or her decision regarding my request. I understand each
question I answered on the questionnaire was responded to
truthfully, accurately and completely. I also understand
that failure on my part to provide truthful, accurate and
complete information to the Consulting Physician could cause
him or her to unknowingly make an inappropriate treatment
decision affecting my physical or mental health. To prevent
this occurrence, I acknowledge that it is of utmost importance
that I am truthful when answering the questions asked in
the Medical History Questionnaire;
Before taking any medication prescribed, I will ensure that
I have completed the following: accurately and honestly completed
a comprehensive physical examination by my primary care Physician;
that I received a copy of the written report of said examination,
and that I have identified my responses to the Medical History
Questionnaire any findings from my physical examination that
are not within the accepted average range;
Allaboutdietdrugs.com does not practice medicine. I understand
that Allaboutdietdrugs.com 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 source, independent and separate
from Allaboutdietdrugs.com and is not an agent or employee
of Allaboutdietdrugs.com or its affiliates. Allaboutdietdrugs.com
does not direct, control or influence the treatment decisions
made by the Consulting Physician with respect to my care
and/or my request from Allaboutdietdrugs.com. Allaboutdietdrugs.com
is not liable for any negligent act or omission of the Consulting
Physician;
I understand that my medical record becomes the property
of the Consulting Physician and not Allaboutdietdrugs.com,
but that, in addition, Allaboutdietdrugs.com could have continuing
access to and the right to copy and retain any and all portions
of my medical record;
I am over 18 years of age;
I am soliciting this site for informational and educational
purposes, in part to determine whether I meet the criteria
for certain prescription medications. However, the Consulting
Physician will be the determinant be the sole judge of whether
you meet the criteria necessary to be granted a prescription
medication. I am not currently seeing my regular primary
care Physician at this time because: a) this site is more
convenient, b) for other personal reasons;
I agree that any dispute arising out of or related to the
provision of services by the Consulting Physician, by Allaboutdietdrugs.com,
its affiliates, or their employees, partners and agents,
shall be subject to mandatory mediation. Should mediation
fail to resolve the disputable issue(s), said dispute shall
be subject to final and binding arbitration, as set forth
in the United States Arbitration Act.
In accordance with the United States Arbitration Act, I
agree that any dispute arising out of or related to the provision
of services by the Consulting Physician, by Allaboutdietdrugs.com,
its affiliates, or their employees, partners and agents,
shall be subject to final and binding arbitration exclusively
through the Procedures of the American Arbitration Association.
I understand that this agreement is voluntary and that it
is binding to any individual or entity claiming by or through
me or on my behalf; and I chose this site on my own accord
from several Internet options;
Any mediation, arbitration, administrative proceeding, complaint,
court proceeding, or other proceeding pertaining in any way
to this site must be held in the County of Palm Beach, City
Del Ray Beach, and in no other forum in any other place.
This Informed Consent expressly includes knowing consent
to transfer the venue of any dispute of any kind to the above
city and county for resolution.
I hereby release Allaboutdietdrugs.com and the Consulting
Physician from all claims that the Consulting Physician acted
unprofessionally or below the standard of care solely because
he/she did not perform a physical examination on me. Your
physical exam will be given by your primary care Physician
before you seek permission to have a prescription medication
filled.
This release includes, but is not limited to, my agreeing
to the following:
I have truthfully answered all of the questions and have
provided complete and accurate answers to the questions.
I further agree to make the Consulting Physician aware of
any changes in my medical condition in the event I revisit
this site to obtain more or different medication;
I am aware of potential side effects associated with this
medication. I personally accept all risks involved in taking
medication and will not seek any indemnification, any damages
of any kind, or any other liability from Allaboutdietdrugs.com,
its parent, subsidiaries, affiliates, contractors, or partners,
if I experience any of the side effects;
I understand that no doctor, nurse, or administrative personnel
can guarantee that the prescription medicines I am requesting
will provide the results I seek;
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 my taking this
medication inappropriate or dangerous;
I have consulted with my Physician and/or pharmacist and
am not currently taking any medications or combination of
medications that will make the medication I am requesting
inadvisable to take (contraindicated); and,
I will notify my primary care Physician that I am taking
the medication that I requested so that he/she may advise
me as to whether or not I should begin, continue or discontinue
its use.
This document also serves as my informed consent to allow
Allaboutdietdrugs.com access to any of my medical information,
including all medical data contained in the Medical Records
Questionnaire including, but not limited to, any health information
regarding HIV, mental health, alcohol, drug or substance
abuse conditions or treatments ("Medical Information")
or pregnancy. I hereby authorize my Physician to release
or disclose to the Consulting Physician any and all Medical
Information. I accept that, with the exception for action
formerly taken with regard to this authorization, I can void
this authorization at any time by providing notices to Allaboutdietdrugs.com
or to the Consulting Physician. This consent does not give
Allaboutdietdrugs.com, its parent or sister companies, the
right to sell my name or information to any third party.
In consideration of Allaboutdietdrugs.com's undertaking
to render the undersigned patient any administrative or any
other services relating in any way to this agreement, or
Allaboutdietdrugs.com disclosing information or methods of
treatment to patient (either of which are deemed sufficient
consideration for this agreement) then, in the event any
court determines that the undersigned patient sought medical
treatment or medical prescriptions through Allaboutdietdrugs.com
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 Allaboutdietdrugs.com, its procedures, officers,
directors, 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
Allaboutdietdrugs.com, its officers, directors, shareholders,
affiliates, banking relationships, contractors, medical laboratories,
contracting Physicians, medical protocols, sources of pharmaceuticals,
proprietary medical treatment protocols or the Consulting
Physicians system of pharmaceuticals procurement and dispensing,
then the undersigned patient knowingly, expressly and irrevocably
consents to a judgment in favor of Allaboutdietdrugs.com,
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 patients employer) as an authorized
or apparent agent of his/her principle or employer, in the
amount of Three Million Dollars ($3,000,000.00), 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 engaged in such deception or any of the above described
acts, agrees on behalf of himself and his/her principle,
to pay all reasonable attorneys 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.
I understand that all prescription medications purchased
cannot be refunded.
ALL INFORMATION, ITEMS, AND SERVICES CONTAINED ON THIS WEB
SITE ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY
KIND, EXPRESSED OR IMPLIED.
IN USING THIS WEB SITE, I UNDERSTAND AND AGREE; (A) THAT
Allaboutdietdrugs.com IS NOT RESPONSIBLE FOR THE NEGLIGENT
OR INTENTIONAL ACTS OR OMISSIONS OF ANY HEALTH CARE PROVIDER
OR SUPPLIER THAT I MAY BE LINKED WITH OR FOR ANY ACTION OR
INACTION TAKEN BY ME IN RELIANCE UPON THE INFORMATION COMMUNICATED
TO ME VIA THIS WEB SITE; (B) THAT THE TOTAL LIABILITY OF
Allaboutdietdrugs.com AND ITS AFFILIATES, IF ANY, ARISING
FROM OR RELATED TO INTERACTIONS I HAVE WITH OR THROUGH THIS
WEB SITE (WHETHER THE CLAIM IS CONTRACT, TORT, WARRANTY,
NEGLIGENCE, MALPRACTICE, FRAUD, OR OTHERWISE) IS LIMITED
TO THE PURCHASE PRICE OF ANY PRODUCTS IN ANY RELEVANT TRANSACTION
AND (C) THAT Allaboutdietdrugs.com SHALL NOT BE LIABLE FOR
ANY DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL,
OR PUNITIVE DAMAGES.
IN ACCORDANCE WITH THE ABOVE UNDERSTANDING, I AGREE TO RELEASE
Allaboutdietdrugs.com, THEIR EMPLOYEES, AGENTS, CORPORATE
AFFILIATES AND RELATED PARTIES FROM ANY AND ALL LIABILITY
ASSOCIATED WITH OR ARISING FROM THE PHYSICIAN CONSULTATION
OR FROM THE MEDICAL, PHYSICAL, BEHAVIORAL OR OTHER EFFECTS
OF ANY MEDICATION THAT MAY BE ORDERED, PRESCRIBED OR PURCHASED
AS A RESULT OF THE PHYSICIAN CONSULTATION.
IF ANY PROVISION OF THIS ABOVE AGREEMENT IS HELD TO BE VOID,
UNENFORCEABLE OR ILLEGAL, THEN I AGREE THAT THE AGREEMENT
WILL BE CHANGED OR LIMITED ONLY TO THE EXTENT NECESSARY TO
ENABLE THE REMAINING PROVISIONS TO BE OF FULL FORCE AND EFFECT.
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