It is important to us that
you, the patient, be fully informed about any potential risks associated with taking
Viagra. Please read thoroughly and acknowledge this page so the doctor can perform your
consultation.
I agree
that:
I have read
the available information from the pharmaceutical
manufacturer regarding potential side effects associated with this medication. I am aware,
as well, that no physician, nurse, counselor or administrator has any knowledge or can
have any knowledge as to whether I might or might not experience success or adverse effect
from this medication.
By going forward, I am stating that I am acting as an individual with the exclusive
interest of obtaining VIAGRA� for personal use for the
treatment of compromised sexual performance with the goal of managing sexual dysfunction.
I further
state that I have no other interests, professional or personal, in the investigation of VIAGRA�.
I elect to use this medication of my own choice, of my own expense, and assume all
responsibility should I participate further. I understand that I am obligated to have
complete annual history physical examinations and appropriate laboratory studies to ensure
that I am in good health.
I also
understand that:
- If I have failed to furnish
accurate or complete medical information or if I have failed to inform the doctor of any
changes in my medical condition, that there is no way that they can advise me
appropriately, nor can I or will I hold them responsible for any adverse effects that may
occur.
- Viagra is a prescription
drug, only available from a licensed physician after a medical consultation and health
history. [Please click here to read detailed product
information from the manufacturer to find out if VIAGRA� is
right for you.]
- This series of questions
(which would normally be asked in a physician's office), includes relevant medical history
and specific data regarding compromised sexual function and the use of this specific
medication and is in no way a substitute for a general medical history and physical
examination, with special attention to blood pressure and cardiopulmonary (heart and lung)
status, for determining general good health.
- Your general health is our
first concern. Over the past decade, more emphasis has been placed on preventive health
care for men and important new diagnostic tests have become available. Therefore, we will
specifically ask if you have been evaluated by a physician in the last year and determined
to be in good general health.
By clicking the button below, labeled "Click here for the
consultation form," I hereby release supplier, and any and all of supplier's
employees from any and all liability, whatsoever, associated with my participation in the
VIAGRA� program.
Your credit card will only
be billed the $75 medical consultation fee if you are approved. Questions? Please see the FAQ. |