I hereby release FFD, Inc. and all of their employees and contractors including physicians from all liability associated with my Viagra® consultation and/or the use of Viagra®.  I understand that no physician, nurse or administrative personnel can guarantee that Viagra®, even if prescribed, will provide the results I seek. I hereby agree to answer truthfully all of the medical questions during my consultation.  I also understand that if I fail in anyway to furnish FFD, Inc. with my complete and accurate medical history or become aware of any changes in the future which I have not notified FFD, Inc. of then I cannot hold them responsible for any adverse effects I may suffer.

I realize Erectile Dysfunction (ED) may be caused by underlying medical conditions such as but not limited to cancer, diabetes or conditions involving the cardiovascular system.  Viagra® may control your (ED) but it does not treat these possible-underlying conditions.  I also understand that cardiovascular events can be associated with sex and other strenuous activities with or without the medication.

I am fully aware that it is my responsibility to have an annual physical exam, including any suggested laboratory test, to ensure that I have no disease, which might make Viagra® inappropriate for me.  I also understand that this consultation is not a substitute for my need to visit a local physician for my annual exam. I further agree to notify all physicians, whose present care I am currently under or any physician who I will engage in the future, of my decision to use Viagra® so they may advise to continue or discontinue the use of medication.

I understand that the side effects of Viagra® include, but are not limited to, facial flushing, mild headaches, congestion, diarrhea, urinary tract infections and visual changes to color sensitivity. For more information regarding ViagraŽ please contact Pfizer Pharmaceuticals @ www.viagra.com. I further agree if I am taking nitrates in any form, even occasionally, I should not take ViagraŽ.   Nitrates are found in many prescription medications that are used to treat angina or chest pain due to heart disease.  I will take precaution concerning the transmission of sexual diseases and I will seek immediate medical attention if an erection persists longer than three hours.  I understand that Viagra® is to be taken only once per 24-hour period and the standard dose is 50mg.  Finally, I understand a qualified licensed physician, who may or may not be licensed to practice medicine in my state, will evaluate the information I am providing.

If approved, I irrevocably appoint FFD, Inc to be my agent and have my prescription and any refills filled by the Pharmacy of its choice and acknowledge that the Rx obtained for me is non-transferable. We are unable to accept returns or issue refunds for any orders due to the fact that this is a prescription medication.