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This document must be carefully read and personally signed by the person to whom the prescription was issued for the products that
I, the undersigned, represent, acknowledge, and confirm to Aids Drugs Online ("ADO"), to the pharmacies that fill the Prescription (as that term is defined below) on behalf of ADO ("Supplying Pharmacies"), to each of ADO's and the Supplying Pharmacies' directors, officers, shareholders, employees, agents, contractors, sub-contractors, affiliates, and service providers ("Agents"), and to the successors and assigns of ADO, the Supplying Pharmacies, and the Agents:
1. I provide this Release, Authorization, and Agreement for the purpose of inducing ADO to enter into one or more present or future contracts with me for the supply of prescription products ("the Contract").
2. I understand that ADO will rely upon the representations set out in this Release, Authorization, and Agreement and upon any other information that I otherwise provide to ADO.
3. The following representations are true:
1. Pursuant to the laws applicable in the jurisdiction in which I am ordinarily resident ("Place of Residence"), I am of the age of majority, and I am legally competent to make, and not otherwise restricted from making, decisions about my health care, medical treatment, and well-being.
2. The prescription products that are the subject matter of the Contract ("Prescription Products") were lawfully prescribed to me personally by a duly-qualified medical practitioner who is authorized to practice medicine in my Place of Residence ("Prescribing Doctor"), and the prescription was not obtained through fraud, deceit, or other dishonesty or illegality.
3. The Prescription Products will not be used in any way by anyone including me, except in accordance with the directions of the Prescribing Doctor and then only by me.
4. The prescription that I provide to ADO ("Prescription") is either the complete and unaltered original prescription that the Prescribing Doctor issued or a true, accurate, and complete copy of that original prescription.
5. The Prescription has not been filled prior to being provided to ADO, and, where I have not provided the original Prescription to ADO, I undertake to destroy all copies of the Prescription immediately after entering into the Contract and shall not fill the Prescription elsewhere.
6. I shall submit to regular medical examinations by, or under the supervision of, the Prescribing Doctor to ensure that my use of the Prescription Products will not cause adverse medical effects, and I shall immediately contact the Prescribing Doctor if I notice any unintended or unexpected adverse effects arising out of my use of the Prescription Products.
7. I understand that ADO, the Supplying Pharmacists, and the Agents merely provide the Prescription Products in accordance with the instructions of the Prescribing Doctor and that ADO, the Supplying Pharmacies, and the Agents do not provide medical advice, and I shall not rely upon them for medical advice or health care needs. Instead, for such advice and needs, I shall solely rely upon the advice of the Prescribing Doctor or another duly-qualified medical practitioner who is authorized to practice medicine in my Place of Residence.
8. I have fully and truthfully disclosed to ADO all personal and medical information and documents that are relevant to the Contract ("Relevant Materials"). I undertake to notify ADO immediately if, during the term of the Contract, there are any changes to the Relevant Materials.
I, the undersigned, hereby authorize and appoint ADO as my agent and attorney, from the date on which I execute this Release, Authorization, and Agreement and continuing in force until revoked by me in writing, for the limited purpose of taking such actions and executing such documents on my behalf as may be required to fulfil the Contract to the same extent as I could do if I were present to take such actions and execute such documents myself, including, but without limiting the generality of the foregoing: the collection, clarification, or verification of medical or health-related information about me from the Prescribing Doctor or any other third party; the disclosure of medical or health-related information about me to the Supplying Pharmacies or the Agents; and, the execution of documents, including additional releases and authorizations directed at the Supplying Pharmacies, the Agents, or other third parties, and documents relating to packaging, shipping, and delivery of the Prescribed Products.
In addition to the representations made in this Release, Authorization, and Agreement, I, the undersigned, hereby enter into, and agree to be bound by, all of the terms in their entirety and without modification as set out in the following agreements and statements (the "Further Terms"):
Signed at the City/Town of _____________________
in the State/Province of _______________________
in the Country of ____________________________
on the _____ day of _______, 20____.
Patient Medical Questionnaire (All Information is Required Before Orders are Shipped)
1) High Cholesterol Y ___ N ___
2) High Blood Pressure Y ___ N ___
3) Diabetes Y ___ N ___
4) Heart Disease or Stroke Y ___ N ___
5) Edema or excessive fluid retention Y ___ N ___
6) Gastrointestinal diseases such as ulcers,
gastroesophageal reflux, ulcerative colitis or Crohn’s disease Y ___ N ___
7) Thyroid disorder Y ___ N ___
8) Cancer Y ___ N ___
9) Lung or upper respiratory diseases Y ___ N ___
10) Smoker Y ___ N ___ 20) Prostate disorder Y ___ N ___
11) Glaucoma or other eye disorder Y ___ N ____
12) Kidney disease Y ___ N ____
13) Liver disease Y ___ N ____
14) Muscle or joint disorders such as arthritis, gout, fibromyalgia, carpal tunnel Y ___ N ____
15) Emotional disorders such as depression, psychosis, etc. Y ___ N ____
16) Immune disorders such as HIV, AIDS, Lupus etc. Y ___ N ____
17) Allergies to dust, pollen, etc Y ___ N ____
18) Skin disorders such as acne, psoriasis, etc Y ___ N ___
19) Neurological disorders such as Parkinson’s, seizures, Alzheimer’s, stroke, migraines, etc. Y ___ N ___
Important: If you answered YES to any of the above questions or you have any other illness not noted above please elaborate below:
Attach original prescription here, and FAX to: 1-866-795-9461
Please fill out all information completely and accurately.
You may also scan/email this information to us by sending an email to: