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.