Patient Responsibility Statement and Informed Consent for EU pharmacy
In submitting the attached questionnaire form, I affirm and attest as if under oath that the following statements are true and correct:
I am an adult at least 18 years of age who is competent to utilize the
services offered by and fully understands the material contained on this
I have previously used the medication(s) requested, under a physician's supervision, without any adverse effect, or I have been advised by my examining physician that I may safely use the medication(s) requested.
I have no knowledge that any of the medications provided to me through use of this website are contraindicated.
The laws of jurisdiction in which I reside permit me to receive and use the edication(s) requested for my personal medical needs.
I have recently submitted to a comprehensive physical examination and medical history evaluation by a local physician of my choosing who is available and whom I agree to promptly contact, in case I have any questions, difficulties or complications, for any necessary local follow-up care and intervention.
I understand that I am being provided telephone numbers with which I may contact the prescribing physician and dispensing pharmacy, and that I should keep those telephone numbers with me at all times in case of emergency or questions. I understand that such physician is an independent practitioner and not an employee or principal of euapoteket.com.
I have been afforded the opportunity to ask any and all questions of relevant and appropriately trained health care personnel and understand the risks, benefits, and potential side effects of the medication(s) requested, and have separately investigated the written materials relating to these drugs including the websites and links that
offer such material.
I am requesting that a european. licensed physician act only in a adjunct capacity to my local physician, and not replace my local physician to authorize the prescription
drug(s) for dispensing by the clinic's associated licensed pharmacy.
I have fully and completely disclosed any and all information concerning my health and medical history that might possibly be relevant to my current condition and need for medication.
I request the medication(s) solely for my own medical needs, and will not distribute, sell, or otherwise dispense the medication(s) to any other persons. I do not request the medication(s) in order to provide or add to a stock of such medication. The medication(s) I now seek to no exceed the amount necessary for my current medical needs.
I understand that certain over-the-counter medications may react with prescription medications and agree that I will not take any over-the-counter medications prior to obtaining approval from my pharmacist or physician.
I will monitor my blood pressure at least once every 10 days. If my systolic pressure (the top number) is over 140 or my diastolic pressure (the bottom number) is greater than 90, I agree to stop taking this medication and consult my physician immediately.
I am the owner of the credit card with which I will purchase the medication(s) or I am permitted by law to use such credit card.
I understand that, for my safety and well-being, I must and will respond to questions asked of me regarding my medical history and symptoms with the utmost veracity, in the same manner I would answer my examining physician when under his or her care.
I understand that there are risks as well as benefits in taking any medication. I have been fully apprised of the possible risks and benefits of the medications prescribed hereunder.
I agree that I have been provided sufficient information and adequately understand same, with at least as much clarity as if this consultation had taken place with my local physician in person.