STATEMENT OF CUSTOMER RESPONSIBILITY
INFORMED CONSENT AND AUTHORIZATION

The following Statement of Customer Responsibility; Informed Consent and Authorization sets forth the terms of the arrangement under which Health Solutions Network is providing you the medication(s) you requested, and your agreement to accept responsibility for your decision to seek medication(s) from Health Solutions Network. In order to fill your requested order, you verify that you have read and understand these conditions.

I. Statement of Customer Responsibility

INFORMED CONSENT AND AUTHORIZATION

• I am an adult (at least 18 years of age) and am competent to utilize the products offered by Health Solutions Network and I fully understand the material contained on this website.
  
  
• I chose this site on my own accord from several Internet options
  
  
• I recognize that the prescribing physician reviewing my Medical History Form will approve or reject my request for medication based upon my responses. I am aware that my failure to provide truthful, accurate and complete information to the prescribing physician could result in an inappropriate treatment decision that could be harmful to me. Therefore, I have responded to each question on the Medical History Form truthfully, accurately, and completely and have fully and completely disclosed any and all information concerning my health and medical history that could possibly be relevant to my current condition and need for medication. I have either previously used the medication(s) requested, under my personal primary care physician's supervision and without any adverse effect, or have been advised by my personal primary care physician that I may use the medication(s) requested.
  
  
• I have no knowledge that any of the medication(s) that I have requested are contraindicated because of other medications I am taking or for any other reason.
  
  
• I have a personal physician and had a physical examination and medical history evaluation within a year of making a request for medication. I agree to undergo a physical examination every year to ensure that my request for medication is appropriate. I will contact my personal physician if I have questions, difficulties or complications in connection with taking the requested medication(s).
  
  
• I have either previously used the medication(s) requested, under my personal primary care physician's supervision and without any adverse effect, have not been informed by my personal primary care physician that I should not use the medication(s) requested.
  
  
• I will make my prescribing physician aware of any changes to my medical condition in the event I revisit the site to obtain more or different medication.
  
  
• I understand that Health Solutions Network will receive electronic transmission of my request for a physician consultation and will direct that request for a prescribing physician’s review and response in accordance with the physician’s professional judgment.
  
  
• I understand that I am being given telephone numbers with which I may contact the prescribing physician who will review my Medical History Form and the pharmacy, and that I should also keep those telephone numbers with me at all times in case of emergency or questions. I also understand that the physician reviewing my Medical History Form is an independent, U.S. licensed practitioner, is not an employee or principal of Health Solutions Network, and also is not my personal primary care physician.
  
  
• I understand that the prescribing physician is compensated by Health Solutions Network for reviewing the Medical History Form without separate charge to customers. The prescribing physician is compensated for this review whether or not the physician issues or decides against issuing the prescription based upon the history and information provided.
  
  
• I have been given the opportunity to ask any and all questions about the medication(s) I have requested. I have to separately review the written materials relating to these medications, including the websites and links identified on Health Solutions Network website.
  
  
• I understand that there are risks as well as benefits in taking any medication. I have been fully apprised by Health Solutions Network and my personal physician of the possible risks, benefits, and potential side effects of the medication(s) I have requested.
  
  
• I request the medication(s) solely for my own medical needs, and will not distribute, sell, or otherwise dispense the medication(s) to any other persons. I do not request the medication(s) in order to provide or add to a stock of such medication. The medication(s) I now seek do not exceed the amount necessary for my current personal medical needs.
  
  
• I understand that certain over-the-counter medications, including herbal medicines and nutureuticals, may react with prescription medications, and I agree that I will not take any of these over-the-counter medications prior to obtaining approval from my pharmacist or personal primary care physician.
  
  
• I will monitor, or ask someone to routinely monitor, my blood pressure. If my systolic pressure (the top number) is over 140 or my diastolic pressure (the bottom number) is greater than 90, I agree to stop taking this medication and consult my personal primary care physician immediately. I will also monitor myself for side effects that may result from the medication I requested which may include nausea; vomiting; dizziness; faintings; irregular or fast heartbeat; lack of appetite and sweating and will stop the medication and consult my personal primary care physician.
  
  
• I am the owner of the credit card with which I will purchase the medication(s), or I am permitted by law to use such credit card.

II. Customer Agreement and Acknowledgement

• I am seeking medical consultation for the purposes of obtaining medications that I request via the Internet through Health Solutions Network of my own volition, and I realize that the physician reviewing my medical history will not conduct an in-person physical examination and will rely on the truthfulness and accuracy of the information I am providing on my Medical History Form.
  
  
• I am utilizing this site either because I am seeking a specific prescription medication to treat an already-identified medical condition, or to determine whether or not I fit the criteria for certain prescription medications.
  
  
• I understand that a physician who is currently licensed in the United States will review my Medical History Form. As such, I acknowledge that the prescribing physician may be located in a state other than my own, and that such physician may NOT be licensed to practice in my state. Therefore, I agree that all online medication consultations, diagnoses, and treatments will be deemed to have occurred in the state where the physician reviewing my Medical History Form is licensed to practice medicine.
  
  
• I am under the care of a personal primary care physician and I do not consider the prescribing physician to be my personal primary care physician.
  
  
• I am aware of the potential side effects associated with this medication.
  
  
• I acknowledge that Health Solutions Network does not practice medicine. I further acknowledge that Health Solutions Network cannot and does not direct, control or influence the medical opinions or decisions made by the prescribing physician with respect to my care.
  
  
• I agree that any dispute arising out of or related to the provision of products by Health Solutions Network, by the prescribing physician, or by their affiliates, employees, partners and agents, will be subject to mandatory mediation. Should mediation fail to resolve the dispute issue(s), said dispute shall be subject to final and binding arbitration of mutual agreement.
  
  
• Any mediation, arbitration, administrative proceedings, or other proceedings shall be held exclusively in Montgomery County, Pennsylvania and shall be governed by the laws of the Commonwealth of Pennsylvania.
  
  
• I accept all risks, known and unknown, involved in, arising from or related to taking the medication(s) I request. Subject to and without waiving any rights that may be conferred upon me under state or federal law, I will not seek indemnification and/or damages whatsoever of any kind from Health Solutions Network for negligent, reckless or intentional acts or omissions, and I hereby hold harmless Health Solutions Network from and against any and all liability relating to or arising out of my request for or receipt of medications from Health Solutions Network.
  
  
• I hereby release Health Solutions Network and the prescribing physician from any and all claims that the prescribing physician acted below the requisite standard of care solely because he/she did not personally examine me.
  
  
• I hereby acknowledge that all information and service provided by or through this web site are provided "as is" without warranty of any kind, expressed or implied.
  
  
• If any provision of this agreement is held to be illegal, void or unenforceable, then this agreement may be modified or amended only to the extent necessary to enable the remaining provisions to be of force and effect to the maximum degree.
  
  
• I acknowledge that, once my medication order has been approved for delivery, no prescription medication may be returned for a refund, in whole or in part.
  
  

III. Privacy Statement

• As part of the processing of your order through Health Solutions Network, you will be asked to provide certain individually identifiable personal information, including your name, email and mailing address, telephone number, billing information (including your credit card number or checking account information), in addition to other information to facilitate the ordering, billing, or payment process. This information is maintained in a secure encrypted form and is not given, sold, traded, or otherwise provided to third parties unless legally required. Individually identifiable health information provided on the Medical History Form or as a part of any medical consultation will not be released other than to the prescribing physician and the pharmacy or to the subscriber or the subscriber’s authorized representatives or designated agent.
  
  
• Health Solutions Network will have continuing access to and the right to copy and retain any and all portions of my medical records and information.
  
  
• Your IP address is logged and may be used to administer our website and diagnose any problems with our server, or prevent fraud.
  
  
• We may also use the information you provide us to send you information about your order, additional information about the site, or information about special offers or products through us or our affiliated companies that you might be interested in receiving, unless you request not to receive such information. Our site uses “cookies” to help us identify you as a prior customer, retrieve information you provided previously, and otherwise personalize your interaction with our site. You should refer to your browser instructions or help menu if you would like information on whether your browser enables you to block cookies, receive a warning before a cookie is stored, or remove cookies from your computer's hard drive.
  
  
• Health Solutions Network is not responsible for the content of any other third party site linked to this site or any other site through which you accessed Health Solutions Network, and you should refer to those sites for any applicable terms of use or their privacy or security policies.
  
  
• If you need to update, modify, or change your information in our database or if you choose to opt-out of receiving future communications from us contact us by email at customerservice@healthsol.net

IV. Customer Authorization for Release of Protected Health Information

In connection with providing certain individually identifiable health information to Health Solutions Network, I authorize the following:

• I hereby authorize Health Solutions Network to use and disclose any of my health information, including all individually identifiable health information contained in the Medical History Form for the purpose of treatment, payment and health care operations. This authorization additionally includes, but is not limited to, any health information relating to HIV and other sexually transmitted diseases, mental health or disease, drug or alcohol treatments (“Protected Health Information").
  
  
• I hereby authorize the prescribing physician to release or disclose to Health Solutions Network any and all Protected Health Information. I realize that I can void this authorization at any time by providing written notices to Health Solutions Network or to the prescribing physician, except with respect to any action already taken pursuant to this authorization.
  
  
• Our privacy notice, located on our website, provides more detailed information about our privacy policies, and you are encouraged to review it before signing this authorization.