1. I am a competent adult at least 18 years of age.

2. I am permitted by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic purposes.

3. I, the patient, have had a recent satisfactory and sufficient physical examination and medical history evaluation by a local physician who is available and whom I agree to contact for any necessary local follow-up care and intervention, in case I have any difficulties, possible complications, or questions. I know also that I may contact the prescribing physician and the dispensing pharmacy, and I will keep those toll free numbers available.

4. I have been fully informed by appropriately trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request, I have studied written or internet materials on these drugs including the web sites and links that offer in-depth material.

5. I also affirm that I have previously safely used the medication(s) I may request, under a physician's supervision, or I been advised by my examining physician that the use of the medication(s) is not contraindicated for me and is appropriate for my personal therapeutic and medical needs.

6. 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.

7. I am requesting that a U.S. licensed prescriber act only in an adjunct capacity to my local physician, and not replace my local physician, when reviewing my request. I further request the prescriber to authorize the prescription drug(s) for dispensing by the clinic's associated licensed pharmacy.

8. I affirm that I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand.

9. 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.

10. I agree not to take any over-the-counter medicines without approval from my pharmacist.

11. I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking this medication immediately.

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

13. I affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local physician's office and under that physician's care, I have fully and completely disclosed any and all information concerning my health and medical history that my possibly be relevant to my request for this medication.

14. I realize there are risks as well as benefits to any medication, even OTC drugs. I have been fully informed of the possible effects, risks, and benefits of this medication. I agree that I have been previously and recently examined sufficiently as to physical and medical condition, and I have been provided sufficient information and adequately understand, the same as or more than if this consultation had taken place with my local physician in a physical office setting.