By requesting medication through www.MigrainePill101.com, I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:
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I am an adult, capable of entering legal contacts, and at least 18 years of age.
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The laws in my geographical location permit the delivery of the requested medication(s).
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All questions asked of me during the medication request have been answered truthfully and completely.
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I will not distribute the requested medication(s) to others.
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I have had a recent physical examination by a local, licensed medical physician. Based on the results of my physical and medical history, my doctor has informed me that I should use the requested medication(s).
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I know that all medication(s) have associated risks. I understand that using and medication(s), including "over-the-counter" medication, has both benefits and risks.
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I will contact the prescribing physician and pharmacy immediately upon any complications, issues, or questions regarding the requested medication(s).
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I understand the benefits, side-effects, and risks of the requested prescription medication(s). I have read written and/or internet literature and have no additional questions.
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Knowing all the risks associated with the requested medication(s), I consent to treatment.
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I have used the requested mediation(s) in the past while under a licensed doctor's care. I have been advised by my doctor that the requested medication(s) is proper for my immediate medical needs.
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I am requesting prescription medication for my own personal medical purposes
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I request that a U.S. Licensed Medical Doctor assist my local Medical Doctor by prescribing the requested medication(s)
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I request the prescribing doctor to allow the fulfillment of the requested medication(s) by a licensed pharmacy.
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I do not request the prescribing doctor to replace the opinion of my local physician.
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I am requesting ONLY the needed amount of medication(s) for my condition and am not attempting to create a reserve, or stockpile of medication.
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I will not take any other medication(s), including "over-the-counter" medication, without prior approval from my pharmacist.
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I am the authorized cardholder of the credit card used for payment of the requested medication.
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I have provided ALL information concerning my health and medical history so that the pharmacist and prescribing doctor may properly review my request.
Informed Consent Agreement
By requesting medication through www.MigrainePill101.com, I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:
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By requesting medication through www.MigrainePill101.com, I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:
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I am an adult and I am aware of the potential side effects associated with ALL medications; both prescribed and non-prescribed.
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I have answered truthfully all of the medical questions on my questionnaire. I understand that no doctor, pharmacist, or administrative personnel can guarantee that the requested medication(s), even if prescribed, will provide the results I seek.
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Additionally, I understand that even if prescribed, I may suffer adverse effects from the requested medication(s).
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I am voluntarily requesting medication(s) of my own choice, at my own expense and my own liability and assume all responsibility for the use of any medication(s).
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I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I have no disease(s) that might make the medications inappropriate for my condition.
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I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I am not taking any medications or combination of medications that are on the published list of medications that are contraindicated with these medications.
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I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I am not taking any medications or combination of medications that are on the published list of medications that are contraindicated with these medications.
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I am responsible for all customs, tariffs, and taxes, if applicable.
I authorize the contracted pharmacy for which I have ordered from, to fill the prescription for the medication I am requesting. I understand the medication will be shipped within 1 to 2 business days after approval.
