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CONTENTS_TABLE
2 WAY MIRRORS
ACTUATORS
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BB SPECIALS
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BUGS
CAP GUNS
CARNIVEROUS
CCTV
CCTV BOARDCAM
CCTV CAMERAS 1
CCTV CAMERAS 2
CCTV CASES
CCTV COVERT
CCTV DVR
CCTV DOMESTIC
CCTV GLOSSARY
CCTV HOME
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CCTV SWITCHERS
CCTV WIRELESS
CCTV 3KM RANGE
CCTV 2.4GHZ
CO2 CONTROL
CO2 RIFLES
CORAL CALCIUM
CONTACT
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DETOX
DOOR CHIMES
DIY
ELECTRONIC KITS
FART BOMBS
FLYING THINGS
FREE GIFT
GARDEN
GENERIC V

GENERATORS

GREENHOUSE

GROW STUFF

GROW LIGHTS

GROW MEDIUM
GUN CARE
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HALLUCINOGENIC
HEALTH
HEATERS
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Holiday Home Exchanges SPAIN 1
Holiday Home Exchanges SPAIN 2
HOLSTERS
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INKJET BROTHER
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INVERTERS
INFRA RED
KEY TRACKER
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NUCLEAR
NUTRIENTS
NIGHT VISION
OPTICAL
OPTICAL ACCESSORIES
OXACCELERATOR
PAINT BALL
PELTIER
PIPES
PLINKING
POWER SUPPLIES

PRINTING

PROPAGATION

PUB GAMES

PUMPS
RADAR
RADIOS
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REPLICA
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RF KITS
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SLINGSHOTS
SOFT AIR
SOFTWARE
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ARCADE
ART & FONTS
ANIMALS
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TRUTH
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WEEDS

WILESCO STEAM 1

WILESCO STEAM 2
WILESCO STEAM 3
WINCHES
WIND TURBINES
WORMS
YUKON BINOS
YUKON NIGHTVIS
YUKON SPOTTING

 

You must fill out this section if you are ordering Vega

Do you have any of the following conditions? Leukemia, Multiple Myeloma, Sickle Cell Disease, Peptic Ulcers, or Retinitis pigmentosa?

 

Do you take any form of  nitroglycerine ?

 

Have you previously been treated for sexual dysfunction?

 

Date of Birth : 

    e.g., 06/14/65

Sex : 

 
     

Do you have high blood pressure? (greater than 140/90)

I agree not to take any over-the-counter medicines without approval from my pharmacist

I agree to monitor my blood pressure at least once every 14 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

I agree to not take this medication if I am pregnant, breast feeding, or trying to get pregnant


Please list any current medical conditions: (If none type 'None')


Please list all medications you are currently taking: (If none type 'None')


Please list all medications that you plan to take while on this program: (If none type 'None')


Please list all allergies (including medications): (If none type 'None')


Please list any surgeries: (If none type 'None')


Is there anything else in your medical history you deem relevant? (If none type 'None')

 

PATIENT RESPONSIBILITY STATEMENT


By submitting this consultation form I affirm as if under oath and state truthfully that:

I am a competent adult at least 18 years of age.

I am permitted by law in my locale to receive the medication(s) I am requesting for my personal medical and therapeutic purposes.

I, the patient, have had a satisfactory and sufficient physical examination and medical history evaluation by my personal family physician within the last 6 months who is available and whom I agree to contact for any necessary local follow-up care and intervention, in case I have any difficulties, possible complications, or questions. 

I have been fully informed by appropriately trained health care personnel and understand the risks, benefits, and possible side effects of the prescription drug(s) I may request, I have studied written or internet materials on these drugs including the websites and links that offer in-depth material.

I also affirm that I have previously safely used the medication(s) I may request, under a physician's supervision, or I been advised by my examining physician that the use of the medication(s) is not contraindicated for me and is appropriate for my personal therapeutic and medical needs. 

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. 


I affirm that I am seeking the perscription(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 agree not to take any over-the-counter medicines without approval from my pharmacist. 
I agree to monitor my blood pressure at least once every 14 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. 


I affirm that I have answered and will answer all questions truthfully, for my safety, just as I would in my local physician's office and under that physician's care, I have fully and completely disclosed any and all information concerning my health and medical history that my possibly be relevant to my request for this medication. 

I realize there are risks as well as benefits to any medication, even OTC drugs. I have been fully informed of the effects, risks, and benefits of this medication. I agree that I have been previously and recently examined sufficiently as to physical and medical condition, and I have been provided sufficient information and adequately understand, the same as or more than if this consultation had taken place with my local physician in a physical office setting. 

I ACCEPT (enter your full name here) 

 

 

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