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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 FioricetBargain.com is voluntary.

b. I understand that the  physician reviewing my Medical History Questionnaire will confer with my primary care physician if deemed necessary, and I attest that I have undergone a comprehensive, in-person physician examination by my primary care provider.

c. 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. I will not seek any indemnification, any damages of any kind, or any other liability from FioricetBargain.com, its parent, subsidiaries, affiliates, contractors, and or partners.

d. I understand that I have a right to access the personal information FioricetBargain.com has collected about me 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.

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