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 AmeriPills.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;
AmeriPills.com does not practice medicine. I understand that AmeriPills.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 AmeriPills.com and is not an agent or employee of AmeriPills.com or its affiliates. AmeriPills.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 AmeriPills.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 AmeriPills.com, and that, in addition, AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.com or to the Consulting Physician. This consent does not give AmeriPills.com, its parent or sister companies, the right to sell my name or information to any third party.
In consideration of AmeriPills.com's undertaking to render the undersigned patient any administrative or any other services relating in any way to this agreement, or AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.com, its officers, directors, shareholders, affiliates, banking relationships, contractors, medical laboratories, contracting physicians, medical protocols, sources of pharmaceuticals, proprietary medical treatment protocols or AmeriPills.com's system of pharmaceuticals procurement and dispensing, then the undersigned patient knowingly, expressly and irrevocably consents to a judgment in favor of AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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 AmeriPills.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.