PATIENT RESPONSIBILITY STATEMENT AND INFORMED CONSENT

Statement of Patient Responsibility
1. I am A COMPETENT ADULT at least 21 years of age,
2. I am permitted by law in my locale to receive the medication(s) I am requesting FOR MY PERSONAL MEDICAL AND THERAPEUTIC PURPOSES,
3. 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 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 THE PRESCRIBING INTERNET PHYSICIAN AND THE DISPENSING PHARMACY, AND I WILL KEEP THOSE TOLL FREE NUMBERS AVAILABLE.
4. 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,
5. I ALSO AFFIRM THAT I have PREVIOUSLY safely used the medication(s) I may request, under a physician's supervision, or I have 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,
6. 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,
7. 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 the virtual clinic's associated licensed pharmacy,
8. I AFFIRM THAT I am seeking the prescrition(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand,
9. I will promply contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication,
10. I am allowed by law to use the credit card that will be used if my request is approved and processed and realize there are NO RETURNS allowed on prescription medicine,
11. I FULLY UNDERSTAND AND agree that the credit card will be charged (doctor's consult fee) if the licensed prescriber authorizes the requested medication, and that this fee applies to any approved order for the authorized prescription for a 4 month period,
12. I FULLY UNDERSTAND AND agree, upon approval, I am receiving the same as or MORE THAN the standard level of care from a U.S. FLORIDA PHYSICIAN,
13. 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,
14. I realize there are risks as well as benefits to any medication, even Over The Counter drugs. I HAVE been FULLY informed of THE possible 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 AS IF THIS CONSULTATION TAKEN PLACE WITH MY LOCAL PHYSICIAN IN A PHYSICAL OFFICE SETTING.


Please Read the Consent to Medical Care
Note: (For first time orders, a consultation fee will be charged for approval of your medical form. No fee will be charged if you are denied by the doctor.) In consideration of A.E.T.N.A. accepting my medical profile and application to purchase the prescription medication®, and selling me the prescription medication ® in the event my application is approved, I hereby certify that I am over the age of 21, am acting of my own volition and am fully aware of the risks and possible consequences of consuming the prescription medication ®. I certify that I am not taking any medications which are contraindicated with use of the prescription medication ®. I hereby release A.E.T.N.A., its officers, directors, and executive management personnel, administrators, employees, contractor, pharmacies, doctors, successors and assigns, (the 'Released Parties') from all actions, causes of actions, suits, sums of money, contracts, controversies, agreements, promises, damages, judgments, executions, claims and demands whatsoever, in law or in equity, which I ever had, now have, or hereafter can, shall or may have against the Released Parties by reason of my purchasing the prescription medication ® from A.E.T.N.A., and consuming same, with full acknowledgment that I may be releasing claims of which I have no knowledge. I represent and warrant that (1) all the information I provide in connection with my purchase from A.E.T.N.A. is true and correct; (2) I am not taking any medication which is contraindicated with use of the prescription medication ®; (3) I do not have any health condition which would increase my risk of suffering an adverse reaction from taking the prescription medication ®; (4) I understand the Waiver and Release terms above; (5) I will undergo an examination by a physician prior to taking the prescription medication ®; and (6) I am fluent in English and understand everything I am agreeing to, including the complete waiver of any claims I may have against the Released Parties for any reason whatsoever.I also agree (1) to take appropriate and necessary precautions to minimize the risk of an adverse reaction to the prescription medication ®; (2) to seek immediate medical attention in case of such adverse reaction; (3) to immediately stop taking the prescription medication ® following an adverse reaction; and (4) that all services provided to me by any physician included in the Released Parties are deemed to have occurred in the state where the physician is physically located and licensed to practice medicine. I accept these risks and assume the responsibility for my own actions in ordering the prescription medication ® over the Internet, without the benefit of a personal, face to face physical examination by a physician. I also understand that the Released Parties strongly recommend that I get a physical examination from my physician prior to consuming the prescription medication ® and state that I have made an informed decision to forego such examination prior to ordering the prescription medication ®, but will get such an examination prior to consuming the prescription medication ®.I also understand that after a doctor reviews my medical questionaire and determines that the prescription medication ® is appropiate for my condition, I hereby authorize a fee to be charged to my credit card for the doctors consultation. I understand that these charges are in addition to the cost of the prescription medication ®.I agree that A.E.T.N.A. is unable to accept returns or issue refunds for any orders of prescription drugs. I agree to be responsible for all customs, tariffs, and taxes applicable to my country.I have read and understood the Waiver, Release and Representations and Warranties and agree to all the foregoing terms in their entirety.


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