By continuing with this consultation I am affirming and truthfully stating, as if I was under oath, the following:

1. I am an adult of sound mind and judgement and at least 18 years of age. In the case of a patient being under the age of eighteen (18) years, a parent or guardian must accept this agreement and must be present at all consultations.
2. The medication(s) and prescription(s) that I am requesting are entirely for my own personal medical needs only. The medication(s) and prescription(s) requested are required for my condition and will not be used to sell onto any third party or used to stockpile an excess of medication beyond what is an adequate supply.
3. I, the patient, have recently undergone an examination with a registered medical practitioner who has evaluated my current condition and past medical history and deemed this to be to a satisfactory level. I can also affirm that my doctor is available for further consultation if the need arises and I agree to immediately contact my doctor for any necessary check-up, care or intervention in the event that I should experience any side effects or complications or have any questions in respect of the medication(s). I accept that the prescribing doctor may contact me for any reason whatsoever even if I have not requested them to do so.
4. I confirm that I have been informed by an appropriately trained health care professional and fully understand the benefits, possible side effects and risks of the prescription medicine(s) I may request. I have also studied written or internet materials on these treatments including various links and websites that offer in-depth material on the subject.
5. I also affirm that I have used the medication(s) I am requesting under a doctor's supervision and that their use was safe and free from side effects. I also state that I have been advised by my examining doctor that the use of the medication(s) is not contraindicated for me and is appropriate for my personal medical needs.
6. By completing this consultation, I am requesting that an Australian registered doctor act only in an adjunct capacity to my examining general practitioner. I do not wish for this prescribing doctor to replace my regular doctor.
7. I agree to immediately contact a doctor for any necessary medical intervention should a complication or side effect manifest whilst using the medication(s) or at any time thereafter. Before taking any other new medicines, I agree to first obtaining approval from a registered medical practitioner or pharmacist and take full responsibility for doing so.
8. I affirm that all the questions answered in the consultation have been done so honestly and to the best of my knowledge, in the same way I would answer a ‘face-to-face’ consultation with my regular doctor. I understand that full disclosure is essential in maintaining my personal safety for the requested medication(s). I will without fail adhere to this condition of disclosure at all times.
9. As a further affirmation of the previous point, I have openly disclosed all information regarding my medical history that may be relevant. I have in no way omitted or misrepresented any information during the consultation process.
10. I fully understand that there are risks as well as benefits associated with and to the use of any medication or treatment(s). I have not been forced to undergo treatments and or medications that I have or may request and do so out of my own free will.
11. If requesting anti-hypertensive medication, I agree to monitor my blood pressure on a regular basis and consult my examining doctor immediately if my blood pressure is higher than 140/90 (if the top number is greater than 140 or the bottom number is greater than 90).
12. I am permitted by law to use the credit card used to purchase the medication(s) or treatment, if my request is approved.
13. I agree that by proceeding with this request for the chosen medication(s), I am voluntarily agreeing to all of the above mentioned points. I understand that by continuing, I irrevocably bind myself to the terms and conditions contained herein.