I swear, affirm, certify, and warrant that I have carefully and thoroughly read all of the statements and truthfully answered, in all respects, all of the questions contained in this document.
Furthermore, I understand, accept and agree to each of the following statements:
I am over 21 years of age, legally competent, and under no undue emotional distress.
I am choosing HighStoreRx.com 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 understand that use of HighStoreRx.com is voluntary.
I hereby release HighStoreRx.com, it employees, contractors, physicians and pharmacists of any and all liability associated with this consultation and/or the use of medication prescribed.
I understand that the physician reviewing my Medical History Questionnaire will confer with my primary care physician if deemed necessary, and I attest that I have undergone a comprehensive, in-person physician examination by my primary care provider.
I understand there are potential side effects associated with taking any medication. Further, I have reviewed other materials on these medications and prescription drugs including other web sites and links that provide information about these medications and prescription drugs.
I will not seek any indemnification, any damages of any kind, or any other liability from HighStoreRx.com, its parent, subsidiaries, affiliates, contractors, and or partners.
- I understand that I have a right to access the personal information HighStoreRx.com has collected about me and correct any inaccuracies.
I will answer each question as accurately as possibility and truthfully.
I understand that all medications, after they have been shipped, may NOT be returned for a refund. Once shipped, ALL SALES ARE FINAL.
I agree that should any dispute arise out of or related to the provision of services by HighStoreRx.com, its affiliates, or their respective employees, partners and agents as well as any dispute arising out of the services of the Physicians, shall be subject to mandatory mediation. Should mediation fail to resolve the issue(s) in dispute, said dispute shall be subject to final and binding arbitration in accordance with the United States Arbitration Act.