Patient Waiver - User terms
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
a 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 Pain-Medication-Rx.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;
Pain-Medication-Rx.com does not practice medicine.
I understand that Pain-Medication-Rx.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 contractor of Pain-Medication-Rx.com
and is not an agent or employee of Pain-Medication-Rx.com or its affiliates.
Pain-Medication-Rx.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 Pain-Medication-Rx.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 or Pain-Medication-Rx.com,
and that, in addition, Pain-Medication-Rx.com will 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 to determine whether
or not I fit the criteria for certain prescription medications. 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 Pain-Medication-Rx.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 Pain-Medication-Rx.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 Nevada, City Grass Valley,
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 Pain-Medication-Rx.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.
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 Pain-Medication-Rx.com physicians 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 Pain-Medication-Rx.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 continue or discontinue its use.
This document also serves as my informed consent
to allow Pain-Medication-Rx.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"). I hereby authorize my Physician to release
or disclose to Pain-Medication-Rx.com 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 Pain-Medication-Rx.com or to the Consulting Physician.
This consent does not give Pain-Medication-Rx.com, its parent or sister
companies, the right to sell my name or information to any third party.
In consideration of Pain-Medication-Rx.com's
undertaking to render the undersigned patient any administrative or
any other services relating in any way to this agreement, or Pain-Medication-Rx.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 Pain-Medication-Rx.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 Pain-Medication-Rx.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 Pain-Medication-Rx.com,
its officers, directors, shareholders, affiliates, banking relationships,
contractors, medical laboratories, contracting physicians, medical protocols,
sources of pharmaceuticals, proprietary medical treatment protocols
or Pain-Medication-Rx.com's system of pharmaceuticals procurement and
dispensing, then the undersigned patient knowingly, expressly and irrevocably
consents to a judgment in favor of Pain-Medication-Rx.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 Pain-Medication-Rx.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 Pain-Medication-Rx.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 Pain-Medication-Rx.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 Pain-Medication-Rx.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.