Patient Responsibility Agreement

1. By agreeing to and submitting this Patient Responsibility Agreement and the consultation form I confirm as if under oath and state that I’m over the age of 18(EIGHTEEN) and possess the requisite legal capacity to enter into this agreement.


2. The laws in my country do not in any way create an impediment to me receiving any of the medications/treatments that have or will request.


3. The medication/treatments that I have or will request are for my own personal use and I warrant that I will not stock pile or distribute to any third party.


4. That I have recently undergone a full physical examination and that the outcome of this examination was considered to be satisfactory by the Doctor concerned.


5. In agreeing to this medical examination I affirm that I informed the doctor of my full medical history and that in doing so divulged to the fullest extent any medical conditions past or present, including but not limited to all information pertinent to any medications that I may have taken or may still be taking for any condition whatsoever. Including but not limited to prescription and or over the counter treatments/medications.


6. I understand that should I have any concerns before, during or after any such medication/treatment that I should contact a medical practitioner as soon as possible for follow up care or intervention.


7. I understand the risks and or potential side effects that may be associated with prescription drugs and in this regard I have personally satisfied myself with the associated risks by consulting an appropriately trained medical practitioner. I have been fully informed of the possible effects, risks, and benefits of this medication. I warrant that I have undergone a recent medical examination and that it was determined by a medical practitioner that my physical and medical condition was sufficient with the view to undertaking the treatment/medication that I have requested. I further warrant that such medical examination was undertaken with full disclosure on my behalf.


8. I confirm that I have used the medication/treatments that I have requested previously and warrant that I did not exhibit any side effects. I further warrant that if I have not used the treatments/medications previously that I have been advised by my examining doctor alternatively an appropriately trained medical practitioner that the aforementioned is not contraindicated for me and is appropriate for my personal medical needs.


9. By submitting this consultation I hereby request that a licensed prescriber from either the UK or the EU act in a capacity as an adjunct to my own local Doctor. I do not wish for this licensed prescriber to replace my local doctor when reviewing my request. In acting in terms of my request I consent to the licensed prescriber authorizing the prescription medication/treatment in my favour for dispensing by the associated licensed pharmacy.


10. Should I experience any complications or have any concerns relating to the use of the medication/treatment requested, which require medical intervention, I warrant that I will immediately contact a registered medical practitioner to obtain the requisite assistance.


11. I confirm that I will not take any other medications/treatments whilst taking the medication/treatment being requested, unless my pharmacist or doctor has confirmed that it is safe to do so. In this regard I will provide a complete list of medications/treatments to my doctor and or pharmacist.


12. I confirm that I will monitor my blood pressure at least once every fortnight and warrant that should the level of my blood pressure cause concern that I will immediately stop taking the medication/treatment.


13. I confirm that I’m legally entitled to use the credit card, debit card etc intended to be used to process this transaction.


14. I warrant that I have answered the abovementioned to the best of my ability and knowledge and that I have disclosed in full all relevant information with regards to my health and medical history and have not misrepresented any information in any manner whatsoever.

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