— I am at least 18 years of age.

— I, the patient, have had a recent physical examination and medical history evaluation by a physician, who is available for any necessary local follow-up care and intervention.

— I have been fully informed and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request.

— I am making this request under a physician’s supervision and I’ve been advised by an examining physician that the use of the medication(s) is not harmful to me and is appropriate for my therapeutic and medical needs.

— I am requesting the prescription medication(s) solely for my own therapeutic and medical needs, and will not distribute the bought medication to others.

— I am requesting that a licensed prescriber act only as an adjunct capacity to my local physician and not replace my local physician, when reviewing my request and authorizing the prescription drug(s) for dispensing by the virtual clinic’s licensed pharmacy.

— I will promptly contact a local physician for any necessary medical intervention should a complication or concern related to the use of a requested medication.

— I am allowed by law to use the credit card that will be used if my request is approved and processed.

— I have and will answer all questions truthfully, for my safety, just as I would in my local physician’s office and care.

— I realize there are risks as well as benefits to any medication, even OTC drugs. Having been informed of possible effects, I consent to the treatment as I have requested.

— I declare that I know that the order is on my behalf, and will be supplied from pharmaceutical facilities world wide.