Patient Responsibility
Patient Responsibility  
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Patient Responsibility

Patient Responsibility

PATIENT RESPONSIBILITY STATEMENT©

By submitting this consultation form I the patient / undersigned affirm as if under oath and state truthfully that I the patient / undersigned agree, understand, and accept that;
- I the patient / undersigned am a competent adult at least 30 years of age;
- I the patient / undersigned am permitted by law to import the medication I am requesting for my personal medical and therapeutic purposes for the country, province, or state that I am importing the medication to;
- I the patient / undersigned understand, and speak the English language fluently;
- I, the patient / undersigned, have had a recent satisfactory and sufficient physical examination and medical history evaluation by a local physician who is available and whom I the patient / undersigned agree to contact for any necessary local follow-up care and intervention, in case I the patient / undersigned have any difficulties, possible complications, or questions. I the patient / undersigned also know that I the patient / undersigned may contact the prescribing physician and the dispensing pharmacy, and I the patient / undersigned will keep those toll free numbers available;
- I the patient / undersigned 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 the patient / undersigned may request, I , the patient / undersigned have studied written or internet materials on these drugs including the web sites and links that offer in-depth material;
- I the patient / undersigned also affirm that I have previously safely used the medication(s) I the patient / undersigned may request, under a physician's supervision, or I I the patient / undersigned have been advised by my examining physician that the use of the medication(s) is not contraindicated for me and is appropriate for my personal therapeutic and medical needs;
- I the patient / undersigned am requesting the prescription medication(s) solely for my own personal therapeutic and medical needs, and will not distribute any of the medication to others.
- I the patient / undersigned am requesting that a licensed prescribing physician act only in an adjunction capacity to my local physician, and not replace my local physician, when reviewing my request.
-I the patient / undersigned further request the prescribing physician to authorize the prescription drug(s) for dispensing by the clinic's associated licensed pharmacy;
- I the patient / undersigned affirm that I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand (3 month supply);
- I the patient / undersigned will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication;
-I the patient / undersigned agree not to take any over-the-counter medicines without approval from my pharmacist or primary local physician;
- I the patient / undersigned 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;
- I the patient / undersigned am allowed by law to use the credit card that will be used if my request is approved and processed;
- I the patient / undersigned affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local physician's office and under that physician'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;
- I the patient / undersigned realize there are risks as well as benefits to any medication, even OTC drugs. I the patient / undersigned 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 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 physician in a physical office setting;
- I the patient / undersigned accept, understand, and agree that any and all contracts and agreements formed throughout the course of the relationship between the patient / undersigned and Humangrowthhormonesales.com, GHSales.com, any of it's operating Incorporated or Limited companies, itís affiliated companies or websites, its president, officers, directors, shareholders, affiliates, banking relationships, independent contractors, agents, couriers, medical laboratories, licensed prescribing physicians, physicians, pharmacists, medical protocols, or any sources of pharmaceuticals, shall be deemed to have been made in the Province of Alberta and accordingly shall be governed by the laws of the Province of Alberta and the laws of Canada as applicable to such contracts and agreements;
- I the patient / undersigned accept, understand, and agree that if any disputes whether civil or criminal arise between the patient / undersigned and Humangrowthhormonesales.com, GHSales.com, any of it's operating Incorporated or Limited companies, itís affiliated companies or websites, its president, officers, directors, shareholders, affiliates, banking relationships, independent contractors, agents, couriers, medical laboratories, licensed prescribing physicians, physicians, pharmacists, medical protocols, or any sources of pharmaceuticals, that all law shall be governed by the laws of the Province of Alberta and the laws of Canada applicable to contracts / agreements formed in the Province of Alberta and I the patient / undersigned understand, accept, and agree that the Courts of the Province of Alberta, Canada shall have sole and exclusive jurisdiction over any dispute whether civil or criminal;
- This agreement represents the complete and entire agreement between the patient / undersigned and of Humangrowthhormonesales.com, GHSales.com, any of it's operating Incorporated or Limited companies, itís affiliated companies or websites, presidents, officers, directors, shareholders, affiliates, the patient, the undersigned, banking relationships, independent contractors, couriers, medical laboratories, licensed prescribing physicians, physicians, pharmacists, medical protocols, sources of pharmaceuticals, or proprietary medical treatment protocols and all parties mentioned above;
- I the patient / undersigned accept, agree, and understand that by checking the indicated necessary marked boxes required, that I the patient / undersigned accept, agree, and understand all the terms and conditions of this agreement, and once the order is submitted I the patient / undersigned accept, agree, and understand that this agreement is considered fully enforceable.

Patient Responsibility
 
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Patient Responsibility