By submitting this request structure, I thus affirm that:
> I am no less than 21 years of age.
> I am allowed by law in my region to gain the medication(s) I am asking.
> I, the patient, have had a later physical examination and restorative history assessment by a M.d who is accessible for any essential nearby catch up consideration and medication.
> I have been completely educated and comprehend the dangers, profits, and conceivable symptoms of the doctor prescribed drug(s) I may ask,
> I securely utilized the medication(s) I may ask for under a doctor's supervision or been exhorted be an analyzing medical practitioner that the utilization of the medication(s) is not contraindicated for me and is fitting for my remedial and medicinal necessities.
> I am asking for the physician recommended medication(s) singularly for my restorative and therapeutic needs, and won't circulate the said medication(s) to others.
> I am asking for that an authorized prescriber act just in an aide limit to my neighborhood doctor, not substituting my nearby medical practitioner, when looking into my appeal, and if approving the professionally prescribed drug(s) for apportioning by the virtual facility's cohorted drug store.
> I am looking for the prescription(s) for the vital supply of solution, not to stockpile past an as of recently satisfactory supply close by.
> I will expeditiously contact a neighborhood doctor for any vital medicinal mediation may as well an intricacy or concern identified with the utilization of the asked for drug emerge.
> I have and will address all inquiries truthfully, for my security, all in all as I might in my nearby doctor's office and forethought.
> I acknowledge there are dangers, and also profits, to any prescription, even OTC pills, and having been educated of conceivable impacts, I agree to medicine as I may ask for and take full and complete obligation.