By submitting this order form, I hereby certify that:

I am a male and at least 18 years of age,

I am permitted by law in my locale to receive the medication(s) I am requesting,

I, the patient have had a recent physical examination and medical history evaluation by a physician, who is available for any necessary local follow-up care and intervention,

I have been fully informed and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request,

I am requesting the prescription medication(s) solely for my therapeutic and medical needs, and will not distribute any said medication to others,

I am requesting that a licensed physician act only in an adjunct capacity to my local physician, not as a replacement for the services provided by my local physician, That I will inform my local physician that I am now taking this medication if approved.

I am seeking the prescription(s) for a necessary supply of medication, not to stockpile beyond an already adequate supply on hand,

I will promptly contact a local physician for any necessary medical intervention should a complication or concern 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 and processed,

I have and will answer all questions truthfully, for my safety, just as I would in my local physician's office and care,

I realize there are risks as well as benefits to any medication, even OTC drugs, and have been informed of possible effects,

I agree never to share this medication with female persons or children.

I am requesting that when filling my prescription for compounded medications that they be shipped to me in non-child proof packaging and marked as such.

I request that my order be processed and shipped to ME directly as a service for my personal use.

I am requesting that on my behalf my medications be shipped to me directly that once filled at the pharmacy they become my property and available for pickup and delivery.

I understand that medications will not exceed a 90 day supply for personal use. As will any prescription medication I agree not to share it with others.