By requesting medication through (), I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:

I hereby release and all of its employees and contractors including physicians from ANY AND ALL liability whatsoever associated or connected with my request for and use of prescription medication(s).

I am an adult and I am aware of the potential side effects associated with ALL medications; both prescribed and non-prescribed.

I have answered truthfully all of the medical questions on my questionnaire. I understand that no doctor, pharmacist, or administrative personnel can guarantee that the requested medication(s), even if prescribed, will provide the results I seek.

Additionally, I understand that even if prescribed, I may suffer adverse effects from the requested medication(s).

I am voluntarily requesting medication(s) of my own choice, at my own expense and my own liability and assume all responsibility for the use of any medication(s).

I fully understand that it is my responsibility to have an annual physical examination, including any suggested lab tests, to ensure that I have no disease(s) that might make the medications inappropriate for my condition.

I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I am not taking any medications or combination of medications that are on the published list of medications that are contraindicated with these medications.

I further agree to immediately notify any doctor whose present care I am under that I have chosen to take medications so that they may advise to continue or discontinue use. I understand that is unable to accept returns or issue refunds for any orders due to the fact that this is a prescription medication.

I am responsible for all customs, tariffs, and taxes applicable to my order. I authorize the contracted pharmacy for which I have ordered from, to fill the prescription for the medication I am requesting. I understand the medication will be shipped within 1 to 2 business days after approval.