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By requesting medication through eShopRX.com, I, the requestor, confirm the following truthful statements as if under oath and subject to penalties of perjury:

  1. I am an adult and at least 18 years of age, capable of entering legal contracts.

  2. The laws in my Country permit the delivery of the requested medication(s).

  3. I have had a recent physical examination by a local, licensed medical physician. Based on the results of my physical and medical history, my doctor has informed me that I should use the requested medication(s).

  4. I know that all medication(s) have associated risks. I understand that using and medication(s), including "over-the-counter" medication, has both benefits and risks (side effects).

  5. I will contact my local physician for and medical assistance in case I have any complications, issues, or questions regarding the requested medication(s).

  6. I am requesting prescription medication for my own personal medical purposes and ONLY for the needed amount of medication(s) not exceeding my 3 months supply (as per US FDA law) and am not attempting to create a reserve, or stockpile of medication.

  7. I will not distribute the requested medication(s) to others.

  8. I request the prescribing doctor to allow the fulfillment of the requested medication(s) by a licensed pharmacy as generic substitute.

  9. I understand that the online physician cannot physically examine the patient, therefore I have provided ALL information concerning my health and medical history so that the pharmacist and prescribing doctor may properly review my request and issue me a prescription.

  10. I understand that no doctor, pharmacist, or administrative personnel can guarantee that the requested medication(s), even if prescribed, will provide the results I seek. Additionally, I understand that even if prescribed, I may suffer adverse effects from the requested medication(s).

  11. I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I am not taking any medications or combination of medications that are on the published list of medications that are contraindicated with these medications.

  12. All questions asked of me during the medication request have been answered truthfully and completely.

  13. I am voluntarily requesting medication(s) of my own choice, at my own expense and my own liability and assume all responsibility for the use of any medication(s).

  14. I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory tests, to ensure that I have no disease(s) that might make the medications inappropriate for my condition.

  15. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take medications so that they may advise to continue or discontinue use.
  16. I am the authorized cardholder of the credit card used for payment of the requested medication.

  17. I am responsible for all customs, tariffs, and taxes, if applicable.

  18. I hereby release eShopRX and all of its employees and contractors including physicians from ANY AND ALL liability whatsoever associated or connected with my request for and use of prescription medication(s).
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