Verification and Agreements
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 certify that I am 21 years of age or older
I am permitted by law in my locale to receive the medication(s) I am requesting
I have been fully informed and understand the risks, benefits, and possible side effects of the prescription drug(s) I am requesting
I certify that I will use this prescription medication for, and only for, the prescribed use, and that I will not use it in conjunction with any illegal substance
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 certify that I have and will answer all the questions truthfully? I also certify that I have completed this application with the purpose of seeking the service of our affiliated physicians and that they will be relying on the truth and accuracy of my answers in determining whether I should have this medication supplied to me.

CONSENT TO MEDICAL CARE
I hereby release 123-meds.com and its employees, its physicians, dispensing pharmacies, and all related persons from any and all liability whatsoever associated or connected with my participation in ordering medications to treat my illness and ailments.
The manufacturer and the physician affiliates at Secure Medical, Inc. recommend a physical examination and a blood work up by a doctor before taking any medication. I understand that an on-line medical consultation will not include a physical examination. I hereby waive a physical examination at this time and agree to obtain a follow-up medical examination before taking any medication.
I also understand that under Federal law Secure Medical, Inc. is unable to accept returns or issue refunds for any shipped orders of prescription medications. I agree to be responsible for all customs, tariffs, and taxes applicable to my country.

LOCAL PHYSICIAN CONSENT
I understand that the medication above is a prescription medication and therefore, the pharmacy is unable to accept returns or issue refunds for any prescription medication.
I attest to and affirm that my local physician (MD or DO), is fully Aware of my intent to take this prescription medication. Furthermore my physician Approves of me taking this prescription and is aware of All medicines that I am taking and plan to take. I understand that I Must Not take this prescription unless I have consulted with a local licensed physician (MD or DO) who has fully evaluated my condition and Approves of my use of this medicine. I will use this medication Only and Exactly as directed by my local licensed physician. And should I experience any problems, whatsoever, I promise to immediately discontinue this medication and contact my physician or seek treatment at an appropriate medical facility. I will continue to follow-up with my local physician at least once every twelve months, or more often as instructed, for physical exams and laboratory studies.