By submitting this ‘PATIENT STATEMENT OF
RESPONSIBILITY AGREEMENT’ Patient affirms as if under oath and states
truthfully the following:
1.
I am a competent adult at least 18 years of age.
2.
I agree to undergo a physical exam by a physician in my community.
5.
I understand that the local examining physician must complete the
American Medical General, Inc. (“AMG”) physical exam forms and fax or deliver them to
AMG.
6.
I am permitted by law in my locale to receive the medication(s) I am
requesting for my personal medical and therapeutic purposes.
7.
I understand and agree to obtain any follow-up medical care
I require from my primary care physician for any medical care relating to any
prescribed treatment obtained from AMG or National Medical Clinic, Inc. (“NMC”). I do not intend to replace
my primary care physician with the physician who conducts my physical exam and
obtains my medical history with reference to an American Medical or National Medical prescribed
treatment.
9.
I agree to go immediately to my nearest hospital emergency room with
the prescribed medication in the event of any medical emergency with any
medication prescribed by an AMG or NMC physician.
10.
I understand that AMG and NMC provide written patient
instructions for each medical treatment program offered by it and I agree to
comply with such instructions.
11.
I agree to provide an accurate and truthful medical history to the
physician who conducts my physical examination and AMG knowing
that the omission or misrepresentation of any material fact about my medical
history and present medical condition could cause the issuance of an
inappropriate or contraindicated prescription by an AMG or NMC physician
that might cause me serious physical or mental harm.
13.
I represent that I have provided any and all abnormal
medical conditions known to me and all current prescribed medications that I am
taking in reporting my medical history to AMG.
14.
I also represent that I shall inform the local physician who conducts
my physical examination and records my medical history of any and all of my
abnormal medical conditions that are known to me and my current prescribed
medications.
15.
I have been fully informed by my primary care physician regarding the
treatment I have requested from AMG and understand the risks,
benefits, and possible side effects of the prescription drug(s) sought from
American Medical General, Inc. and its independent pharmacies. Further, I have studied
written materials on these drugs including websites and links that
offer in-depth information on these drugs(s).
16.
I also affirm that I have previously safely used the
medication(s) sought through American Medical or National Medical, under a physician's supervision,
or I been advised by my primary care physician that the use of the
medication(s) I seek to purchase is not contraindicated for me and is
appropriate for my personal therapeutic and medical needs.
17.
I am requesting the prescription medication(s) solely for my own
personal therapeutic and medical needs, and will not distribute any of the
medication to others.
18.
I am requesting that an AMG or NMC physician act only in an
adjunct capacity to my local primary care physician, and not replace my primary
care physician or the local physician who conducts my physical examination.
19.
I instruct AMG to assure that the prescribing physician’s
prescription for my purchased medication is delivered to a licensed
20.
I understand that any controlled substance prescription issued by an AMG or NMC
physician shall not exceed a treatment period of six months.
21.
I affirm that I am seeking the prescription(s) for a necessary supply
of medication, not to stockpile beyond an already adequate supply on hand.
22.
I will promptly contact my local primary care physician or local emergency
room for any necessary medical intervention should a complication or concern
result related to the use of the medication obtained through AMG or NMC
physician’s prescription
23.
I agree not to take any over-the-counter medicines without approval
from
my primary care physician or a pharmacist who is aware of medications that I am
then currently taking.
24.
I agree to monitor my blood pressure at least once every 7 days. If my
blood pressure is over 140/90 (either the top number is greater than 140 or the
bottom number is greater than 90), I agree to stop taking this medication
immediately.
25.
I am allowed by law to use the credit card provided by me as the
means of paymentto AMG.
26.
I am an authorized card holder as determined and recognized by the credit card
issuer of the credit card used to purchase this medical program from AMG.
27.
I affirm that I have answered and will answer all questions relating to
my sought treatment or AMG and/or NMC services and products truthfully, for
my own personal safety.
28.
I shall fully and completely disclose any and all information
concerning my health and medical history that may possibly be relevant to my
request for this medication to the local physician conducting my required
physical examination and to AMG.
29.
I realize there are risks as well as benefits to any medication, even
OTC drugs. I have been fully informed of the possible effects, risks, and
benefits of this medication.
30. I, the Patient,
including the purchaser if different
from Patient, agree in good faith that
Patient shall undergo an NMC or AMG local physical examination; deliver the
physician’s signed and completed NMC or AMG Physical Exam Form to AMG corporate
offices; provide an NMC or AMG requested saliva or blood specimen to the identified
medical laboratory; provide a complete and truthful medical history fo NMC or AMG and
its physicians; and comply in good faith within the time periods specified with
NMC or AMG procedures and policies for obtaining my medical history, providing saliva or blood specimens, and
respond to all NMC or AMG communications so that I may obtain the medical treatment
purchased. In the event I attempt to cancel my order with AMG, or fail to comply
with any term or condition of this provision, and thereby inhibit the effort of
NMC or AMG to perform its contract with me, which is to undertake to obtain the
issuance of my requested prescribed treatment by a physician, then I expressly instruct
NMC or AMG to charge my credit card with $900.00 as liquidated damages as the agreed
estimated damages sustained by NMC or AMG in its unsuccessful attempt to provide me
services. These damages are specified because it is difficult to ascertain
actual financial damages arising from my failure to comply with this provision
or my failure to cooperate after purchasing a medical program. In such an
event, I specifically waive any claim that said amount should not have been
charged to my credit card; any right to dispute such charge to my credit card;
and any and all defenses to such a claim. This provision shall prevail over any
credit card holder agreement that I have entered into with the credit card
issuer or issuing bank. I agree to pay any and all attorneys fees and costs
incurred by NMC or AMG in the enforcement of this provision or this agreement.
31.
I agree that I have been provided sufficient information and adequately
understand; the nature and possible adverse side effects of the medication
sought by me from prescribing physicians of American Medical and knowingly
consent to assuming the risk of adverse side effects.
32.
I agree that my submission, directly or indirectly, of an order to AMG
constitutes my electronic signature at the time of my purchase of this medical program and
affirmation of my representations stated above as though I personally signed
this document.
33.
In consideration of any clinic, physician, laboratory services
provided purchaser (Patient) by AMG, purchaser (Patient) expressly
and irrevocably waives any right to file any type of credit card
dispute with regard to any AMG purchase transaction after
purchaser’s receipt of any of the foregoing services. Therefore,
purchaser (Patient) irrevocably agrees and instructs American
Medical General, Inc. (hereafter “AMG”) to charge the same credit
card provided to AMG by purchaser (Patient) for the payment of the
purchase price of the current medical program ordered by purchaser
form AMG an amount equal to $500.00 for each occasion that an
employee or staff member of AMG expends time responding to a credit
card dispute or preparing documentation initiated by purchaser
following purchaser’s receipt of any AMG provided clinic, physician
or laboratory services. Further, the filing of such a dispute after
receipt of any clinic, laboratory or physician services provided at the expense of AMG is an
admitted material breach of this agreement by purchaser entitling
AMG to an undisputed summary judgment for liquidated damages in the
amount of $20,000.00 and reasonable attorney’s fees and costs
incurred in enforcing this agreement.” The purchaser (Patient) is
not entitled to a refund of any portion of the purchase price paid
to AMG for a medical program after any clinic, physician or medial
laboratory services have been provided to purchaser (Patient) at
the expense of AMG.” If purchaser (Patient) files any documents
opposing the motion for summary judgment, then the amount of the
Summary Judgment to be awarded AMG shall increase by an additional
$20,000.00. Purchaser waives all claims and defenses in regard to
this transaction and any action brought against purchaser by AMG
arising from this transaction. In the event of any dispute, the
fees contained in the written confirmation of order provided patient at the
time of sale and the entries of services on the order events log shall be deem conclusive as to the enrollment
program price to be charged patient and services that have been
provided patient in connection with the purchaser’s order.
Jurisdiction and venue for any claim arising from this transaction
shall be Palm Beach County, Florida.
PATIENT
AGREEMENT AND ELECTRONIC SIGNATURE VALID AS ORIGINAL SIGNATURE FOR PURPOSES OF
ENFORCEABILITY OF THIS AGREEMENT
Patient evidences understanding and acceptance of
this Agreement by indicating agreement to its terms when the question of
acceptance is presented on a National Medical Clinic, Inc. or American Medical General, Inc. website. Patient may also be
request to fax American Medical a signed copy of this printed Agreement in some
circumstances. However, a signed printed Agreement is not necessary for this
Agreement to binding on the Patient and American Medical General, Inc. American
Medical manifests its acceptance of this Agreement by receiving this order
submitted online by Patient or purchaser. The purchaser and American Medical
General, Inc., parties to this Agreement, understand and agree to accept all of
the terms, conditions and provisions of this ’PATIENT STATEMENT OF RESPONSIBILITY AGREEMENT’
on the date the
order is submitted to American Medical General, Inc. or to National Medical Clinic, Inc. by Patient or employee or agent
of American Medical General, Inc. at the request of patient. It shall be deemed a conclusive presumption
of fact that the employee or agent of
American Medical General, Inc. was specifically authorized by the purchaser and
Patient to enter this order on behalf of purchaser and Patient, including the electronic
signatures of purchaser and patient if the data entered in connection with this
transaction includes personal information of purchaser and Patient of the type
that would not be know by the agent or employee of American Medical General,
Inc., including, but not limited to any one of the following: purchaser or
patient’s social security number, date of birth, phone number or address.
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