Patient Responsibility Agreement

By submitting this consultation form I affirm as if under oath and state truthfully that:

1. I am an adult of sound mind and judgement and at least 18 years of age.



2. I am permitted by the laws in my country to receive the treatment / medications I am requesting for my personal medical treatments.



3. I, the patient, have had a recent satisfactory and sufficient physical examination and have had my medical history evaluation by a local doctor who is available and whom I agree to contact for any necessary local follow-up care and intervention, in case I have any difficulties, possible complications, or questions. I know also that I may contact the prescribing doctor and the dispensing pharmacy, and I will email doctor@121doc.com to arrange for the prescribing doctor to call me back.



4. I have been fully informed by appropriately trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request, I have studied written or internet materials on these drugs including the websites and links that offer in-depth material.



5. I also affirm that I have previously safely used the medication(s) I may request, under a doctor's supervision, or I been advised by my examining doctor that the use of the medication(s) is not contraindicated for me and is appropriate for my personal medical needs.



6. I am requesting the prescription medication(s) solely for my own personal medical needs, and will not distribute any of the medication to others.



7. I am requesting that a UK or EU licensed prescriber act only in an adjunct capacity to my local doctor, and not replace my local doctor, when reviewing my request. I further request the prescriber to authorise the prescription drug(s) for dispensing by the clinic's associated licensed pharmacy.



8. I affirm that I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand.



9. I will promptly contact a local doctor for any necessary medical intervention should a complication or concern result related to the use of a requested medication.



10. I agree not to take any other medicines without approval from my pharmacist. I will tell him/her the full list of other medications that I am currently taking including the one currently being ordered here.



11. I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately.



12. I am allowed by law to use the credit card that will be used if my request is approved and processed.



13. I affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local doctor’s office and under that doctor's care, I have fully and completely disclosed any and all information concerning my health and medical history that my possibly be relevant to my request for this medication.



14. I realise there are risks as well as benefits to any medication. I have been fully informed of the possible effects, risks, and benefits of this medication. I agree that I have been previously and recently examined sufficiently as to my physical and medical condition, and I have been provided sufficient information and adequately understand, the same as or more than if this consultation had taken place with my local doctor in a physical office setting.

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