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:

 

 

a. I am over 21 years of age, legally competent, and under no undue emotional distress. I understand that use of Pillscare.com is voluntary.

 

 

b. 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.

 

 

 

c. 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 pillscare.com, its parent, subsidiaries, affiliates, contractors, and or partners

 

 

d. I understand that I have a right to access the personal information Pillscare.com has collected about me and correct any inaccuracies. I also understand that I may request a written copy of my medical record and that I will be charged a reasonable administrative fee for copying and mailing such records.

 

 

e. I agree that should any dispute arise out of or related to the provision of services by Pillscare.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.