Need help translating this page? Try Google Translate
I hereby release NationwidePharmacies.co.uk and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my prescription medications request and/or use of those prescription medications. I hereby state that I am an adult and that I am aware of the potential side effects associated with prescription medications. I understand that no doctor, nurse, or administrative personnel can guarantee that prescription medications, even if prescribed, will provide the results I seek. Further, I understand that even if prescribed, I may suffer adverse effects from prescription medications. I hereby release NationwidePharmacies.co.uk and all of its employees and contractors including physicians from any and all liability whatsoever associated with any adverse effects I may suffer from my use of the prescription medications provided. I am participating in this programme at my own choice, at my own expense and my own liability and assume all responsibility for my use of any prescription medications provided. 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) which might make the use of prescription medications inappropriate for my condition. 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 which would make any prescription medications provided contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take the prescription medications provided so that they may advise to continue or discontinue use. I wish to have prescribed and supplied to me branded product that is as inexpensive as possible, without prejudice to the other factors that are to be considered by those prescribing my pharmaceuticals and those fulfilling the prescriptions.
By accepting this disclaimer, I the patient confirm that I provide NationWide Pharmacies consent for the following;
- To have my medication despatched by Royal Mail Tracked Service on the day of or after my prescription has been issued
- For the data I provide to be electronically stored by NationWide Pharmacies patient record system
- Permission for your Summary Care Record to be accessed by our clinical staff if they asses there is a need to. There is an option in your account which will be set to 'yes' by default. However, the patient can change this to 'no' if they wish to but doing this may result in your order being declined. A patient's Summary Care Record will only be accessed providing an order has been placed for prescription medication.
I am at least 18 years of age. I am permitted by law in my country of residence to receive the medication(s) I am requesting. I have had a recent physical examination by a physician who is available for any necessary follow-up care and intervention. I have been fully informed and understand the risks, benefits, and possible side effects of the prescription medications I may request. I am requesting the prescription medication(s) solely for my therapeutic and medical needs, and will not distribute any medication to others. I certify that I will use this prescription medication for, and only for, the prescribed use, and that I will not use it in conjunction with any illegal substance. I will promptly contact a local physician for any necessary medical intervention should a complication or concern arise as a result related to the use of a requested medication. I am allowed by law to use the credit card that will be used if my request is approved. I do not require a child safety cap on my medication(s) if prescribed. I have and will answer all questions truthfully, for my safety, just as I would with my own doctor. I wish to have prescribed and supplied to me branded products that are as inexpensive as possible, without prejudice to the other factors that are to be considered by those prescribing my pharmaceuticals and those fulfilling the prescriptions. I understand that if I am resident outside the European Union that I will be responsible for any customs, tariffs, and taxes, that may arise. I certify that the foregoing statements made by me are true.
Certification and Warranty of Patient
I hereby certify and warrant that I am an adult and have carefully read and truthfully answer all of the medical questions in my medical consultation with the Nationwide Pharmacies.co.uk doctor. I further certify that I have completed this application with the purpose of employing the service of the NationwidePharmacies.co.uk doctor and that he will be relying on the truth and accuracy of my answers in determining whether I should have the requested prescription medication supplied to me. I understand if I have failed in any way to furnish the NationwidePharmacies.co.uk doctor with my complete and accurate medical history I have therefore not fulfilled my legal obligation to properly inform the doctor. I understand that if in the future my medical circumstances change in contradiction to the information I have provided that it is my legal responsibility to immediately notify the NationwidePharmacies.co.uk doctor and cease all use of the prescribed medication until further notification.