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Informed Consent© and Waiver Form

I understand, accept, and agree to each of the following statements:


1. I am over 21 years of age. I understand that use of the e-Scripts-md.com website is
voluntary and I attest that I initiated contact with e-Scripts-md.com, LLC.

2. I attest that I am accessing this site because I am seeking treatment for an identifiable
medical or cosmetic condition.

3. I am aware that the physician reviewing my Medical History Questionnaire will not have
the opportunity to conduct an in-person physical examination (referred to as the
“Prescribing Physician” throughout the remainder of this document).

4. I attest that I have undergone a comprehensive, in-person physician examination by my


primary care provider within the last twelve months and will provide my Prescribing
Physician with a copy of my medical records related to this examination upon request.
Furthermore, I will report the results of this examination along with any other significant
aspects of my past or present health history or current health status including a list of all
prescription and over-the-counter medication I take once a week or more often on the
Medical History Questionnaire I submitted to e-Scripts-md.com. I also acknowledge that
there is a blank field at the end of the Medical History Questionnaire that allows me to
note any additional information about me the Prescribing Physician should know.

5. I understand that the Prescribing Physician will determine whether it is medically


appropriate for me to receive the medication I have requested based on the information I
provide in the Medical History Questionnaire, and, therefore, I have an absolute
obligation to answer that Medical History Questionnaire completely and in a truthful
manner.

6. I agree to provide the Prescribing Physician with any additional information he or she
requests beyond that which I supplied as part of my Medical History Questionnaire.

7. I also understand that if I fail to answer the Medical History Questionnaire honestly,
accurately, and completely, my inaccurate answers could cause the Prescribing Physician
to unknowingly make an inappropriate treatment decision that could affect my physical
or mental health.

8. I understand that my Medical History Questionnaire will be reviewed by a Prescribing


Physician who is located and is licensed to practice medicine in the United States. I am
aware, however, that the Prescribing Physician analyzing my Medical History
Questionnaire and prescribing any drug treatment may NOT be located or licensed to
practice medicine in the state where I am located at the time I submit my Medical History
Questionnaire to e-Scripts-md.com.
9. I agree that all medical decision-making made by the Prescribing Physician regarding
whether any drug treatment is medically appropriate for me will be deemed to have
occurred in the state where the physician is physically located, and not the state where I
am located, should they be different;

10. I attest I am under the care of a primary care physician and I do not consider the
Prescribing Physician to be my primary care physician. I will not rely on or substitute the
advice given by the Prescribing Physician should it contradict the advice given to me by
my primary care physician.

11. In the event the Prescribing Physician determines the medication I requested is medically
appropriate for me, I agree to notify my primary care physician that I intend to begin
taking such the medication. I recognize it is my responsibility to seek regular physical
examinations, including any suggested laboratory tests, to ensure that I do not have a
condition which will make my taking any medication prescribed by the Prescribing
Physician inappropriate or dangerous;

12. I hereby release e-Scripts-md.com, LLC from any and all claims related to allegations
that the Prescribing Physician acted unprofessionally or below the standard of care solely
because he/she did not perform an in-person physical examination on me. I understand
that, for purposes of determining whether it is medically appropriate for me to receive the
requested medication(s), the Prescribing Physician will form his or her medical opinion
based on review of the information I provide in my Medical History Questionnaire.

13. I acknowledge that e-Scripts-md.com, LLC does not practice medicine. I understand that
e-Scripts-md.com, LLC only offers an on-line forum that allows me to request a
physician evaluation regarding a particular health condition based on the information I
provide on my Medical Health Questionnaire. I further understand that e-Scripts
provides certain management and administrative services to the Prescribing Physicians
such as, but not limited to, storage and maintenance of medical records, marketing
services, and contracting with the web site hosting company.

14. I understand that the Prescribing Physicians are not employees of e-Scripts, rather they
are independent contractors to whom e-Scripts forwards my information for review and
response. Neither e-Scripts-md.com, LLC, nor any of its affiliates, directs, controls or
influences the treatment decisions made by the Prescribing Physician with respect to my
care and/or my request for certain medication(s). Accordingly, I agree not to hold e-
Scripts-md.com, LLC liable for any negligent act or omission of the Prescribing
Physician;

15. I understand that my medical record is the property of the Prescribing Physician, but is
stored and maintained by e-Scripts-md.com. I understand that because e-Scripts forwards
the information I submit to this website to a Prescribing Physician, it has access to all my
personal information including my health information, and has a right to retain and use
any and all portions of my medical record in accordance with the e-Scripts Privacy Policy
posted on this website.

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16. I understand that I have a right to access the personal information e-Scripts.MD, LLC has
collected about me through e-scripts-md.com and correct any inaccuracies. I also
understand that I may request a written copy of my medical record and that I will be
charged a reasonable administrative fee for copying and mailing such records.

17. I agree that any dispute arising out of or related to the provision of services by e-Scripts-
md.com, LLC, its affiliates, or their respective employees, partners and agents as well as
any dispute arising out of the services of the Prescribing Physicians, shall be subject to
mandatory mediation. Should mediation fail to resolve the issue(s) in dispute, said
dispute shall be subject to final and binding arbitration in accordance with the United
States Arbitration Act.

18. In accordance with the United States Arbitration Act, I agree that any dispute arising out
of or related to the provision of services by e-Scripts-md.com, LLC, its affiliates, or their
respective employees, partners and agents, as well as any dispute arising out of or related
to the provision of services by the Prescribing Physician shall be subject to final and
binding arbitration exclusively through the Procedures of the American Arbitration
Association.

19. I agree that any mediation, arbitration, administrative proceeding, or other dispute
resolution proceeding in which e-Scripts-md.com, LLC is a party pertaining in any way
to this site will be held in the County of Cobb, City of Marietta, and in no other forum in
any other place. This Informed Consent expressly includes knowing consent to transfer
the venue of any dispute of any kind to the above city and county for resolution.
Likewise, I agree that any dispute with the Prescribing Physician and which does not
involve e-Scripts-md.com, that involves mediation, arbitration, an administrative
proceeding, or other dispute resolution proceeding shall be held in the county in which
the Prescribing Physician has his/her primary place of business.

19. I am aware that there exists potential side effects associated with taking any medication.
By requesting this on-line evaluation, I personally accept all risks involved in taking any
medication that may be prescribed by the Prescribing Physician and I will not seek any
indemnification, any damages of any kind, or any other liability from e-Scripts-md.com,
LLC, its parent, subsidiaries, affiliates, contractors, or partners, or the Prescribing
Physicians if I experience any of the side effects.

20. I understand that neither e-Scripts-md.com nor the Prescribing Physician makes any
guarantee that the prescription medicines I am requesting will provide the results I seek.

21. This document also serves as my informed consent to allow e-Scripts-md.com, LLC
access to any of my medical information, including all medical data contained in the
“Medical Records Questionnaire” including, but not limited to, any health information
regarding HIV, mental health, alcohol, drug or substance abuse conditions or treatments
("Medical Information"). I hereby authorize my primary care physician to release or
disclose to my Prescribing Physician any and all Medical Information that the Prescribing

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Physician deems necessary to have to form his/her medical judgment. I accept that I can
void this authorization at any time by providing written notices to e-Scripts-md.com,
LLC. I understand that if I void my authorization for my primary care physician to
disclose my Medical Information, that will not apply to Medical Information already in
the possession of e-scripts-md.com or the Prescribing Physician. This consent does not
give e-Scripts-md.com, LLC, its parent or sister companies, or the Prescribing Physician
the right to sell my name or personal or medical information to any third party.

22. In the event any court or administrative body determines that I sought medical treatment
or medical prescriptions through e-Scripts-md.com, LLC or the Prescribing Physician for
the possible or apparent purpose, directly or indirectly, of deception, or disclosing any
false or misleading information pertaining to e-Scripts-md.com, LLC, its procedures,
officers, directors, to any news organization, possible or actual competitor, any type of
governmental agency, any investigator or any party for possible or apparent purposes of
securing any information, confidential or otherwise, about e-Scripts-md.com, LLC, its
officers, directors, shareholders, affiliates, banking relationships, contractors, medical
laboratories, contracting physicians, medical protocols, sources of pharmaceuticals,
proprietary medical treatment protocols or e-Scripts-md.com, LLC's system of
pharmaceuticals procurement and dispensing, then the undersigned patient knowingly,
expressly and irrevocably consents to a judgment in favor of e-Scripts-md.com, LLC, its
officers, or any party proceeding under the authority of this instrument, of liquidated
damages, jointly and severally against the undersigned patient, as well as any express or
apparent principle (including patient’s employer) as an authorized or apparent agent of
his/her principle or employer, in the amount of Three Million Dollars ($3,000,000.00),
which liquidated damage amount is hereby accepted by the undersigned as a reasonable
amount for engaging in such acts of deception and because they are difficult to ascertain.
The undersigned patient engaged in such deception or any of the above described acts,
agrees on behalf of himself and his/her principle, to pay all reasonable attorney’s fees and
costs incurred by any person or entity seeking to enforce this agreement.

23. This agreement represents the complete and entire agreement between the parties to it.

24. I understand that all prescription medications purchased cannot be refunded.

25. ALL INFORMATION, ITEMS, AND SERVICES CONTAINED ON THIS WEB SITE
ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EXPRESSED
OR IMPLIED.

26. IN USING THIS WEB SITE, I UNDERSTAND AND AGREE; (A) THAT e-scripts-
md.com, LLC IS NOT RESPONSIBLE FOR THE NEGLIGENT OR INTENTIONAL
ACTS OR OMISSIONS OF ANY HEALTH CARE PROVIDER, SUCH AS THE
PRESCRIBING PHYSICIAN, e-scripts-md.com, LLC MAY CONNECT ME WITH OR
SUPPLIER THAT e-scripts-md.com, LLC MAY CONNECT ME WITH OR FOR ANY
ACTION OR INACTION TAKEN BY ME IN RELIANCE UPON THE
INFORMATION COMMUNICATED TO ME VIA THIS WEB SITE; (B) THAT THE
TOTAL LIABILITY OF e-scripts-md.com, LLC AND ITS AFFILIATES, IF ANY,

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ARISING FROM OR RELATED TO INTERACTIONS I HAVE WITH OR THROUGH
THIS WEB SITE (WHETHER THE CLAIM IS CONTRACT, TORT, WARRANTY,
NEGLIGENCE, MALPRACTICE, FRAUD, OR OTHERWISE) IS LIMITED TO THE
PURCHASE PRICE OF ANY PRODUCTS IN ANY RELEVANT TRANSACTION
AND (C) THAT e-scripts-md.com, LLC SHALL NOT BE LIABLE FOR ANY
DIRECT, INDIRECT, SPECIAL, INCIDENTAL, CONSEQUENTIAL, OR PUNITIVE
DAMAGES.

27. IF ANY PROVISION OF THIS ABOVE AGREEMENT IS HELD TO BE VOID,


UNENFORCEABLE OR ILLEGAL, THEN I AGREE THAT THE AGREEMENT
WILL BE CHANGED OR LIMITED ONLY TO THE EXTENT NECESSARY TO
ENABLE THE REMAINING PROVISIONS TO BE OF FULL FORCE AND EFFECT.

Revised IC 5-14-02.doc