I affirm and state truthfully as if I was under oath that;

1. I am 18 years of age and an adult of sound mind and judgment.

2. I am permitted by the laws in my country to receive the treatment and or medications that I have requested.

3. The prescriptions and medication(s) that I have requested are for my own personal medical needs. I confirm that I require the prescription(s) for a necessary supply of medication and not to stockpile beyond an already adequate supply on hand, or supply to a third party.

4. I have undergone a recent medical examination which was found to be satisfactory by a registered medical practitioner. I have also had my medical history evaluated recently by a local registered Doctor. I further affirm that my local Doctor is available for consultation if the need arises and I agree to contact him/her for any necessary follow-up, care or intervention in the event that I should experience any difficulties or complications or have any questions in respect of the treatment and medication(s). I’m also aware of the fact that I may contact the prescribing doctor and the dispensing pharmacy and I will email them accordingly to arrange for the prescribing doctor or the dispensing pharmacy to call me back. I also accept that the prescribing doctor or his duly appointed representative may contact me for any reason whatsoever even if I have not requested him to do so.

5. I understand the risks, benefits and possible side effects of the prescription drug(s) I may request. These have been explained to me in detail by the appropriately trained health care personnel. I have also studied both written and online materials on these drugs and or treatments, including various websites and links that offer in-depth material.

6. I also state that I may have on previous occasions used the medication(s) and or treatments that I may request and that the use thereof proved safe and free from side effects. I further state that previous use was under a Doctor's supervision or conversely that I have 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 and physical needs.

7. In completing this consultation and anything associated herewith I am requesting that a registered EU prescriber act as an adjunct to my own local Doctor. At no time do I wish for this registered prescriber to replace my local prescriber when considering my request. As a result I request that the registered prescriber considering my consultation authorize the prescription in respect of the drug(s) requested for dispensing by their associated licensed pharmacy.

8. I agree to immediately contact a registered Doctor for any necessary medical intervention should a complication or side effect manifest whilst using the medication(s) or at any time thereafter.

9. I agree not to take any other medicines without first obtaining approval from a pharmacist or medical practitioner. I agree to divulge to him/her a full list of medications that I am currently taking including the one being ordered from this site. I agree to ensure full disclosure and accept full responsibility in this regard.

10. I agree to monitor my blood pressure and will do so at least once every 7 (SEVEN) days. If my blood pressure is higher than 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I will stop taking this medication immediately and consult a medical doctor as soon as possible and without any further delay.

11. I affirm that I have answered and will answer all questions truthfully and to the best of my ability as if I was undergoing a ‘face to face’ consultation with a registered Doctor. I understand that full disclosure is essential in maintaining my personal safety and that I will without fail adhere to this condition of disclosure at all times.

12. As a further affirmation of the aforementioned I have disclosed in full any and all information concerning my health and medical history that may be relevant to my request for medication. I have in no way omitted or misrepresented any statement of fact relevant hereto.

13. I am fully cognizant of the fact that there are risks as well as benefits associated with and to the use of any medication or treatment. I have been informed of all the possible side effects, risks and benefits of this medication. I re-affirm that I have undergone a recent medical examination with respect to my physical and medical condition. In doing so I provided sufficient information as if this consultation had taken place with my doctor in a physical office setting and in a ‘face to face’ manner.

14. I have not been induced or placed under duress to undergo treatments and or medications or any other treatments or medications that I have or may request and do so out of my own free will and choice.

15. I am permitted to use the credit card and or any other payment card that will be used to purchase the medication(s) or treatment, if my request is approved and processed. If the card used is not in my name, I affirm that I am an authorised card holder or signatory and duly authorised to make use of the card.

16. I agree that by proceeding with this request and by voluntarily agreeing to the above mentioned, that I irrevocably bind myself to the terms and conditions contained herein.