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Form Example

Online Prescription Consent (Example ONLY)

This form is to be completed if you want to have a prescription filled online. This will assist you if you are remote from a pharmacy or the jurisdiction you live in has high cost medications.


1.*Name


2.Mailing address


3.*Gender
 male
 female


4.*Date of Birth month/day/yr


5.*Phone Numbers day night cell\mobile


6.*Height Feet Inches Weight Lbs


7.*email address


8.*Known Drug Allergies if any if none state none


9.*What medications do you currently take? Indicate name , dose and frequency


10.Are you being treated for any medical conditions at present- if yes please list and indicate status


11.*Do you have any of the following conditions?
 no conditions
 migraine headaches
 glaucoma
 epilepsy
 depression
 psychosis
 thyroid disease
 rheumatoid arthritis
 HIV or AIDS
 asthma
 emphysema
 copd
 diabetes
 cancer -please describe above
 colitis
 psoriasis
 eczema
 heart disease -describe above
 peripheral vascular disease
 cerebro-vascular disease
 joint disease
 liver disease
 hepatitis B?
 hepatitis C?
 other condition's describe


12.Are you pregnant?
 yes
 no


13.Are you planning to become pregnant in the next three months?
 yes
 no


14.*I am at least 18 years of age
 yes
 no


15.*I have the services of a local physician for follow up and questions which I may have
 yes
 no


16.*I have been fully informed and understand the risks, benefits, and possible side effects of the medication's I am requesting
 yes


17.*I agree to take the prescribed medication according to the advice of my personal physician and to notify my doctor of any problems I encounter or questions I may have
 yes


18.*I hereby release the owners of "Pharmacy Name" and all of its employees including contractors from any and all liabilities connected with my medication purchase. This included the pharmacy and physician overseas who process my order.
 yes


19.*I understand that the owners and authors of this site as well as the hosting service are in no way sponsored, associated, or affiliated with the organization that manufacture the products sold on our site
 yes


20.I am interested in getting quotes for the following medications


21.*I am aware that there is a no return policy for prescriptions delivered
 yes


22.Please add me to periodic email newsletters for new products or services
 yes
 no


23.I have been aware I can send a prescription with renewals from my personal physician and I can order a repeat by email or phone call
 yes
 no


24.Do you have any other comments?


 
 

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