ACKNOWLEDGEMENT AND CONSENT BY CUSTOMER
As a material inducement for the services to be rendered by fioricetprescriptions.com Website (this "website"). I do hereby acknowledge and agree that:
I am above the age of eighteen (18) years. I am competent to use the services offered by this website and affiliated pharmacy, and I fully understand the material contained on this website and use it of my own free will, and that I did not act under duress or undue influence.
I understand that I am seeking a medical consultation with a consulting prescribing physician and consulting telemedicine physician, and understand fully the importance of the medical questionnaire that I will be/have been required to fill in, and that the consulting prescribing physician will not have the opportunity to physically examine me, and will rely fully on the said medical questionnaire.
I understand and confirm that the medical questionnaire contains my full and honest medical history, and that I have answered the questions truthfully, openly and honestly, and to the best of my knowledge.
I understand that this website is owned and operated by a third party company that refers me (the customer) to a Pharmacy.
I acknowledge that this website does not practice medicine. I further acknowledge that this website or it's owner(s) cannot and do not direct, control or influence the medical opinions or decisions made by the Physician or clinician with respect to my care.
I acknowledge that I have been given the opportunity to ask any and all questions about the medication(s) I have been prescribed. I understand that the Consulting Physician is independent, is not an employee or principal of this website, and also is not my personal physician.
I am aware that my medical questionnaire will be reviewed by an appointed consulting prescribing physician (herein after called the 'Prescribing Physician'), who is registered and licensed to practice medicine in his/her state of residence, but who may not be licensed to practice medicine in my own state. I am furthermore aware that my completed medical questionnaire will be further reviewed by a contracted telemedicine physician (herein after called the 'Telemed Physician') and should this physician deem it appropriate, then he/she will conduct a telephone consultation with me.
I acknowledge that the Prescribing Physician may, upon examining my medical questionnaire, prescribe medication. I acknowledge that the Prescribing Physician may, upon examining my medical questionnaire, decline to issue a prescription for medication. I acknowledge that the Telemed Physician may, upon examining my medical questionnaire and prescription issued by the Prescribing Physician, deem it appropriate to conduct a telephone consultation with me. The Telemed Physician may, with or without conducting a telephone consultation with me, accept or decline the prescription issued to me for medication.
I understand that there are risks as well as benefits in taking any medication. If prescribed a medication, the medication is solely for my own medical needs, and I will not distribute, sell, or otherwise dispense the medication(s) to any other persons. I am not requesting the medication(s) from multiple sources in order to provide or add to a stock of such medication or to exceed the amount necessary for my current personal medical needs.
I have undergone a physical examination by a physician licensed to practice medicine in my state (herein after called the 'Primary Physician') and that the Primary Physician has diagnosed a certain medical condition which I shall specifically disclose on my medical questionnaire. Therefore I am utilising the services of this website to obtain medication for the identified medical condition and not for a medical condition which has not previously been diagnosed as a result of a physical examination by a physician licensed to practice medicine in my state.
I confirm that I will use the medication prescribed by the Prescribing Physician only after consultation with my Primary Physician and that should the Primary Physician recommend that I discontinue the treatment, or alter it, or in any way supplement or reduce it, my Primary Physician's advice regarding the prescribed medication shall take precedence over that of the Prescribing Physician.
I accept that the prescribing medical consultation and the telemed consultation shall be deemed to have been carried out in the Prescribing Physician's and the Telemed Physician's state of residence and professional practice.
I, however, accept that if any importation of medical treatment/prescription drugs into my state of residence should be necessary, this shall be deemed to be for the purposes of continuing the course of treatment commenced in the Prescribing Physician's state only.
I hereby accept again that the Prescribing Physician and the Telemed Physician shall rely upon my medical questionnaire and my telephone consultation should it have been performed. I confirm, regarding my medical questionnaire that:
I have answered all questions truthfully and honestly and to the best of my knowledge.
I understand that any misrepresentation or non-disclosure on my part may affect the decision of the Prescribing Physician, and have not committed either in my medical questionnaire. It will not be a stand in for a full physical examination, which the Prescribing Physician and the Telemed Physician shall not be able to carry out.
I have undergone a full physical examination by my Primary Physician in order to be able to fully and honestly complete the medical questionnaire. Therefore, I hereby agree to indemnify and hold harmless this website, it's Owner(s), Affiliates, the Prescribing Physician, the Telemed Physician and any pharmacy and/or pharmacist who may hereafter dispense the prescription (Dispensing Pharmacy) against any and all liability arising from any condition that I might suffer following medication prescribed by the Prescribing Physician based upon his/her reliance on my medical questionnaire.
I further warrant that I have checked to ensure that the importation of prescription drugs into my state of residence does not violate the laws of my state or any state at which I may accept delivery of medication prescribed for me by the Prescribing Physician.
I acknowledge and accept that this is a third party website that refers me to a pharmacy and this website is not practising medicine in any capacity, but is simply acting as a medium to refer a specific request for treatment to a specific physician.
I understand that the Prescribing Physician and Telemed Physicians are not employees of this website, and that, therefore, no vicarious inability shall attach to this website or it's owner(s) for any acts or omissions of the Prescribing Physician or Telemed Physician.
I understand that in using the facilities of this website the contents of my medical questionnaire, including my medical history becomes the property of the Prescribing Physician and of this website. I also acknowledge that this website has the right to store this information, place it at the continuing disposal of the Prescribing Physician and Telemed Physician, any other persons involved in my treatment, and to continue to copy, retain and use the said information and records relating to me.
I agree that any and all disputes, controversies and claims arising out of or relating to this use of the services provided herein, or concerning the respective rights or obligations of the parties, shall be settled and determined by arbitration with the Commercial Panel of the American Arbitration Association in accordance with the Commercial Arbitration Rules. All Arbitration claims shall be filed with the American Arbitration Association at it's Southfield, Michigan office, or in the event that such an office is no longer in existence, then the closest office to Southfield, Michigan. Claims covered by this agreement to arbitrate include, without limitation, tort claims and claims for violation of any federal, state, or other governmental law, statute, regulation or ordinance. In preparation for the arbitration hearing, each party may utilize all methods and scope of discovery authorized by the Michigan Rules of Civil Procedure. The arbitration award shall be final and binding upon the parties and a judgment may be entered upon it in accordance with applicable law in any court having jurisdiction thereof, including a federal district court, pursuant to the Federal Arbitration Act. Regarding my treatment, received through this website, I confirm that;
I shall seek information from my Pharmacist and/or Primary Physician regarding the risks, benefits, and possible side effects of any medication prescribed by the Prescribing Physician.
I will use such medication under the strict supervision of my Primary Physician, whose advice shall take precedence over that of, and shall not be supplanted by that of, the Prescribing Physician.
I undertake to make contact promptly with my Primary Physician or any medical practitioner for any necessary emergency intervention should a complication arise following my use of the prescribed medication.
I appreciate that there are always attendant risks to the use of any medication. I hereby indemnify this website, it's Owner(s), Affiliates, the Prescribing Physician, the Telemed Physician and dispensing pharmacy from liability if any severe or other side effects should result from my use of the prescribed medication. I personally accept all risks involved in taking the prescribed medication.
I appreciate that no health professional may guarantee that the medication prescribed shall have the desired effects or will provide the results I seek. Further regarding my use of this website , I have used and shall always use these facilities for the purpose only of seeking medical treatment, not for stockpiling drugs to an already adequate supply.
I understand and agree that this website or the owner(s) affiliated with this website shall not be liable for any acts or omissions of its contracting Prescribing Physicians, Telemed Physicians, the Dispensing Pharmacy and of my Primary Physician in advising me or communicating with me with regard to the prescribed medication. The liability if any, of this website shall extend only up to such amount as may represent the purchase price of any medication and products concerned in any relevant transaction.
I agree to release this website, it's owner(s), its employees, agents, principals, corporate affiliates and all related parties from any liability arising from my consumption of prescribed medications and for medical, physical or behavioural and other effects of any medication that I may take as a result of my seeking a consultation via the Internet. I hereby release this website and it's owner(s) and clinician from any and all claims that the physician acted below the requisite standard of care on the basis that the Physician did not personally examine me.
I hereby acknowledge that all information and service provided by or through this web site are provided "as is" without warranty of any kind, expressed or implied.
If any provision of this agreement is held to be illegal, void or unenforceable, then this agreement may be modified or amended only to the extent necessary to enable the remaining provisions to be of force and effect to the maximum degree.
I acknowledge that, once my medication has been delivered, no prescription medication may be returned, in whole or in part.