|
|
|
INFORMED
CONSENT AGREEMENT
WWW.DISCOUNT-HUMAN-GROWTH-HORMONE.COM
|
|
THE
PATIENT / UNDERSIGNED, BEING OVER THE AGE OF 21, HEREBY:
|
| |
Sign
Here _____________________________________________ Date Signed____________________________________________ |
|
1
|
I
the patient / undersigned accept, understand, and agree
to the following:
I the patient / undersigned am freely seeking medical consultation
via the Internet on my own accord. I the patient / undersigned
accept, and agree that I completely understand the english
language. I the patient / undersigned am aware that the
licensed prescribing physician is acting only in accordance
to the terms and conditions that I accept, agree, and
understand to under this agreement. I the patient / undersigned
accept, understand, and agree that the licensed prescribing
physician is not rendering or providing any service or advice to
me whatsoever and is solely relying on my primary licensed
physician's judgement and professionalism whose care I am currently
under. I the patient / undersigned have undergone all neccessary
blood tests and physical examinations required to administer
HGH (human growth hormone) which I the patient / undersigned have
requested from the licensed prescribing physician. I the patient
/ undersigned have been deemed eligible and meet all the requirements
to administer HGH (human growth hormone) and cleared by my primary
licensed physician whose care I am currenlty under to administer
HGH (human growth hormone) or medication that I have requested from
the licensed prescribing physician. I the patient / undersigned
accept, agree, and understand that the licensed prescribing
physician will not consider the consultation by way of the Internet
to be an appropriate and adequate means of evaluating my condition. The
licensed prescribing physician will review the medical
information and agreement that I the patient
/ undersigned have agreed, understood, and accepted to by
submitting this agreement via the Internet. After the
licensed prescibing physician has reviewed the agreement and
all neccessary documents required the licensed prescribing
physician will prescribe the medication requested HGH
(human growth hormone) by the patient / undersigned . I the
patient / undersigned will not make a claim that the licensed prescribing
physician acted unprofessionally, improperly, or below the standard
of care solely because the physician did not personally perform
a physical examination on me. I the patient / undersigned accept,
agree and understand that I will be monitored as required
by the prescribed medication (HGH human growth hormone), by
my primary licensed physician and undergo all
required blood tests, neccessary examinations and conduct
regular physical examinations that is required by the medication
(HGH human growth hormone) prescribed to me by the licensed
prescribing physician;
|
|
2
|
I
the patient / undersigned understand that my medical evaluations,
recommendations, diagnoses, and treatments will be reviewed by a
physician who is licensed. I the patient undersigned acknowledge
and agree that I, under no duress, am aware that my licensed prescribing
physician may be located in another state/province or country other
than my own and that the licensed prescribing physician may
NOT be licensed to practice medicine in my state/province or country
of residence;
|
|
3
|
This consultation and treatment recommendation constitutes
a legitimate physician-patient / undersigned relationship in
the state / province or country where the licensed prescribing physician
is licensed to practice medicine;
|
|
4
|
I
the patient / undersigend acknowledge as if under oath that
it is essential that I agree, understand and provide truthful
answers to the questions or agreements provided through out
this site. The licensed prescribing physician evaluating my
medical information will make a decision based upon my honest responses
to the questions and agreements regarding my request. I the patient
/ undersigned take a solemn oath than the agreement I submitted
via the internet is truthful, accurate and complete on
the questionnaire and agreement. I further understand that failure
on my part to provide truthful, accurate and complete information
in detail to the licensed prescribing physician could
cause him/her or the pharmacist to make an inappropriate treatment
decision that could severly affect my physical or mental health
and in some cases cause death.
|
|
5
|
I the patient / undersigned am under the care of my primary
care licensed physician and do not consider the licensed prescibing physician
to be my primary care licensed physician. I will not rely
on or substitute the advice given by the licensed prescribing physician
should it be contrary to or in conflict with the advice given to
me by my primary care physician. Before taking any medication prescribed,
I will ensure that I have completed a comprehensive physical examination
by my primary care licensed physician;
|
|
6
|
I
the patient / undersigned further agree to make and the
licensed prescribing physician and pharmacist aware of any
changes in my medical condition or medications;
|
|
7
|
I
the patient / undersigned have been advised and made aware
of the risks, benefits, alternatives to, and potential side effects
of this medication and have had the opportunity to ask any questions
that I may have had regarding my health situation and/or treatment;
|
|
8
|
I the patient / undersigned
understand and accept that it is my responsibility to consult
with my primary licensed physician to ensure that I do not
have a condition which will make use of this medication inappropriate
or dangerous;
|
| 9 |
I
the patient / undersigned have consulted with my primary care
licensed physician and / or pharmacist and am not currently
taking any medication or combination of medications that will make
the medication I am requesting inadvisable or contraindicated;
|
| 10 |
I
the patient / undersigned accept, agree and understand that
/ does not practice medicine. I the patient / undersigned understand
that www.discount-human-growth-hormone.com is a Management Service
Organization that received my request for a physician consultation
and, in turn, directs that request to a qualified independent physician
for review and response. The prescribing licensed physician
who reviews questions and agreements and who makes the
medical determination as to whether or not I receive the medication
I am seeking is solely an independent contractor of and is not an
agent or employee of www.discount-human-growth-hormone.com or its
affiliates. www.discount-human-growth-hormone.com does not direct,
control or influence the treatment decisions made by the licensed
prescribing physician with respect to my care and/or my request
from www.discount-human-growth-hormone.com is not liable for any
negligent act or omission of the licensed prescribing physician;
|
| 11 |
I the patient / undersigned accept, agree, and understand
that my medical record becomes the property of the licensed
prescribing physician or www.discount-human-growth-hormone.com,
and that, in addition, www.discount-human-growth-hormone.com will
have continuing access to and the right to copy and retain any and
all portions of my medical records;
|
| 12 |
The
patient / undersigned acknowledges that it is illegal to attempt
to obtain a prescription medication for any reason by providing
false or misleading information or by any other means of deception;
|
| 13 |
In
consideration of www.discount-human-growth-hormone.com undertaking
to render the undersigned / patient any administrative or any other
services relating in any way to this agreement, or www.discount-human-growth-hormone.com
disclosing information or methods of treatment to patient / undersigned (either
of which are deemed sufficient consideration for this agreement),
then in the event any court determines that the undersigned
/ patient sought medical treatment or medical prescriptions
through www.discount-human-growth-hormone.com for the possible or
apparent purpose, directly or indirectly, of deception, assisting
any investigation, or rendering of any type of assistance to, or
disclosing of any information pertaining to www.discount-human-growth-hormone.com
its procedures, officers, directors, consultants, or medical protocols,
to any news organization, possible or actual competitor, any type
of governmental agency, any investigator or any party for possible
or apparent purposes of securing any information, confidential or
otherwise, about www.discount-human-growth-hormone.com, its president, officers,
directors, shareholders, affiliates, banking relationships, independent contractors,
couriers, medical laboratories, licensed prescribing physicians,
physicians, pharmacists, medical protocols, sources of
pharmaceuticals, or proprietary medical treatment protocols, then
the undersigned / patient knowingly, expressly and irrevocably
consents to a judgment in favor of www.discount-human-growth-hormone.com,
its president, directors, officers, or any party proceeding
under the authority of this instrument, of liquidated damages, jointly
and severally against the undersigned patient, as well as any express
or apparent principle (including patient's employer), as an authorized
or apparent agent of his/her principle or employer, in the amount
of six million dollars ($6,000,000), which liquidated damage amount
is hereby accepted by the patient / undersigned as a reasonable
amount for engaging in such acts of deception and because they are
difficult to ascertain. The undersigned / patient, if engaging
in such deception or any of the above described acts, agrees on
behalf of him/her self and his/her principle, to pay all reasonable
attorney's fees and costs incurred by any person or entity seeking
to enforce this agreement;
|
| 14 |
The
patient / undersigned also agrees that if the licensed prescribing physician
approves the patient/undersigned for a requested prescription medication,
then the medication and prescription charges will be deemed to be
earned and will be immediately due and payable and not refundable.
In the case that the patient is denied the prescription medication
requested there would be no administrative fee charged;
|
| 15 |
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 www.discount-human-growth-hormone.com, 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 Mexico and accordingly shall be governed by
the laws of Mexico and the laws of Mexico as applicable
to such contracts and agreements.
|
| 16 |
I
the patient / undersigned accept, understand, and agree that if
any disputes whether civil or criminal arise between the
patient / undersigned and www.discount-human-growth-hormone.com,
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 country and the laws
of Mexico applicable to contracts / agreements formed in the
country and I the patient / undersigned understand, accept,
and agree that the Courts of Mexico, shall have sole
and exclusive jurisdiction over any dispute whether civil or criminal.
|
| 17 |
This agreement represents the complete and entire agreement
between the patient / undersigned and www.discount-human-growth-hormone.com, 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;
|
| 18 |
I the patient
/ undersigned accept, agree, and understand that by
checking the indicated neccessary 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.
Sign Here _____________________________________________
Date Signed____________________________________________
|
|