Patient History

Primary Physician Information

History of Diseases

This section is for the purpose of learning more about your health history. Please read and answer all of the following questions to the best of your knowledge.

Consent:

I understand that the medications I have purchased are prescribed for me based on diagnosis derived from my submitted medical history, blood and lab report, and physical examination. They are to be based exclusively for treatment of this diagnosis.

I will immediately report any adverse side effects related to the use of my medication to PureRx Inc. and discontinue use until advised to resume usage by PureRx Inc.

I will safeguard my medications from loss or theft.

I understand that PureRx Inc. does not cooperate with any insurance companies. If any part of my prescription from PureRx Inc.'s doctors is to be picked up at a local pharmacy, I agree to pay cash for that medication. I will not request that it be processed through my insurance.

I will not sell, share or trade my medications for money, goods or services.

I agree that I will use my medications at the prescribed rate and dosage, and I will keep the medications in its respective labeled container.

I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is illegal to do so.

I attest I am not seeking medical treatment for body enhancement, body building or performanceenhancement or cosmetic enhancement of any kind.

I am seeking this treatment for legitimate medical purposes.

I have read the text above, and I agree to the terms and conditions disclosed herein.