PATIENT RESPONSIBILITY STATEMENT


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

I am a competent adult at least 18 years of age.

I am permitted by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic purposes.

I, the patient, have had a satisfactory and sufficient physical examination and medical history evaluation by my personal family physician within the last 6 months 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 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.

I also affirm that I have previously safely used the medication(s) I may request, under a physician's supervision, or I 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 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 affirm that I am seeking the perscription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand. 

I 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 agree not to take any over-the-counter medicines without approval from my pharmacist. 
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. 


I 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 realize there are risks as well as benefits to any medication, even OTC drugs. I have been fully informed of the 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 ACCEPT (enter your full name here)