INFORMED CONSENT

I swear, affirm, certify, and warrant that I have carefully and thoroughly read all of the statements and truthfully answered, in all respects, all of the questions contained in this document. Furthermore, I understand, accept and agree to each of the following statements:

a. I am over 21 years of age, legally competent, and under no undue emotional distress. I understand that use of Prescribe Pharmacy, Inc is voluntary.

b. I attest that I am seeking treatment for an identifiable medical or cosmetic condition and that is why I accessed this site.

c . I attest and agree that I have previously taken this medication for a pre existing condition that requires the medication that I am requesting a prescription for.

d. I understand that the physician 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). However, I attest that I have undergone a comprehensive, in-person physician examination by my primary care provider within the last twelve months.

e. I attest and agree that I am currently under the care of a primary care physician. I understand the Prescribing Physician is not my primary care physician and I agree 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.

f. I agree to notify my primary care physician that I intend to begin taking any medications, which the Prescribing Physician may deem appropriate. I understand it is my sole responsibility to seek regular physical examinations, including laboratory tests, to ensure that I do not have a condition, which will make taking any medication, prescribed by the Prescribing Physician inappropriate or dangerous as it pertains to me.

g . I agree to provide my Prescribing Physician with a copy of my medical records related to this examination upon request. Additionally, 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 submit to Main Street, Inc.

h. I understand that the information I provide in the Medical History Questionnaire will be the basis for the Prescribing Physician to determine whether it is medically appropriate for me to receive the medication I have requested. Therefore, I attest that I have answered the Medical History Questionnaire completely and truthfully.

i. I understand that failure on my part to honestly, accurately and completely answer the Medical History Questionnaire could result in an inappropriate treatment decision that could affect my physical or mental health.

j. I understand that Prescribe Pharmacy, Inc nor the Prescribing Physician makes any guarantee that the prescription medicines I am requesting will provide the results I seek.

k. I agree to provide the Prescribing Physician with any additional information that is requested beyond that which I supplied as part of my Medical History Questionnaire.

l. I understand and agree that the Prescribing Physician who will be reviewing my Medical History Questionnaire is located and licensed to practice medicine in the United States.

m . I understand it is possible 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 Prescribe Pharmacy, Inc. Therefore, I agree that any and all decisions made by the Prescribing Physician as to the appropriateness of any drug treatment for me will be deemed to have occurred in the state where the physician is physically located and not in the state where I am located, should they be different.

n. 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 strictly on review of the information I have provided in my Medical History Questionnaire. Therefore, I hereby release Prescribe Pharmacy, Inc 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.

o. I understand there are potential side effects associated with taking any medication. Further, I have reviewed other materials on these medications and prescription drugs including other web sites and links that provide information about these medications and prescription drugs. 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 Prescribe Pharmacy, Inc, its parent, subsidiaries, affiliates, contractors, or partners, or the Prescribing Physicians if I experience any of the side effects.

p . I understand that Prescribe Pharmacy, Inc 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 acknowledge that Prescribe Pharmacy, Inc does not practice medicine.

q . I understand that Prescribe Pharmacy, Inc 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.

r. I understand that Prescribe Pharmacy, Inc does not employ the Prescribing Physicians, rather they are independent contractors to whom Prescribe Pharmacy, Inc forwards my information for review and response. Neither Prescribe Pharmacy, Inc nor any of its affiliates controls, directs 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 Prescribe Pharmacy, Inc liable for any negligent act or omission of the Prescribing Physician.

s . I understand that my medical record is the property of the Prescribing Physician, but is stored and maintained by Prescribe Pharmacy, Inc. I understand that because Prescribe Pharmacy, Inc 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 Prescribe Pharmacy, Inc Privacy Policy posted on this website.

t. I understand that I have a right to access the personal information Prescribe Pharmacy, Inc has collected about me through Prescribe Pharmacy, Inc 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.

u . I agree that should any dispute arise out of or related to the provision of services by Prescribe Pharmacy, Inc, 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.

v . In accordance with the United States Arbitration Act, I agree that any dispute arising out of or related to the provision of services by Prescribe Pharmacy, Inc, 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.

w . I agree that any mediation, arbitration, administrative proceeding, or other dispute resolution proceeding in which Prescribe Pharmacy, Inc is a party pertaining in any way to this site will be held in the County of Miami-Dade, 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 Doctors Online, Inc, 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.

x. I agree this document also serves as my informed consent to allow Prescribe Pharmacy, Inc 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 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 Prescribe Pharmacy, Inc. I understand that if I void authorization for my primary care physician to disclose my Medical Information, it will not apply to the Medical Information already in the possession of Prescribe Pharmacy, Inc or the Prescribing Physician.

y. I understand this consent does not give Prescribe Pharmacy, Inc or the Prescribing Physician the right to sell my name or personal or medical information to any third party.