I am seeking treatment for a medical condition and I understand that no drug, even if prescribed by a physician, is guaranteed to improve my conditions.

I am an adult and of my own choice am selecting the NoHealthInsurance.Net as my agent for collecting and transmitting my medical data to a physician for review and to fill the precription and any refills at a pharmacy of its choice.

I hereby release NoHealthInsurance.Net, it employees, contractors, physicians and pharmacists of any and all liability associated with this consultation and/or the use of this drug.

I will answer each question accurately and truthfully. I understand that physicians and pharmacist will review this questionnaire and can only perform an effective evaluation of my medical history if it is complete and accurate.

I understand that there is no guarantee that a physician or a pharmacist will approve my request for treatment with this drug.

I am aware that there may be side effects associated with this or any pharmaceutical drug.

I agree to assume any and all responsibility or liability arising from the use of this drug.

I will notify my personal physician of my use of this drug and discontinue its use if so recommended by my physician.

I am requesting that a U.S. licensed physician 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.

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.

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.

I will pay all shipping costs, customs duties, tarrifs and taxes, if any, which are applicable in the country where this product is to be shipped.

I understand that pharmaceuticals, after they have been shipped, may not be returned for a refund. Once shipped, all sales are final.

I agree to personally sign for this product when it is delivered. I agree to immediately inspect the shipment and notify the carrier of any problems before signing for the shipment. If I waive the signature or have a signature on file with the shipper I assume total responsibility for lost, missing, or damaged shipments.