I hereby appoint Brocamed Ltd. and its delegates or contractors as my agent and attorney for the purpose of obtaining a prescription from a resident Medical Doctor which corresponds to the prescription included in this order, which may include directly contacting my prescribing physician and purchasing and arranging delivery of the medications prescribed. Substantially on the terms set forth below, all to the same extent I could if I personally took such steps. I hereby consent to Brocamed Ltd., the resident MD and any pharmacy supplying my order, collecting my personal and medical information, maintaining the information necessary to quickly process future orders which may include retaining on file my name, address, e-mail, phone number, payment and other information and verifying future orders.

I represent that all of the following statements are true and agree that Brocamed Ltd. and its contractors are relying on these representations:

1. I am of age of majority or older where I reside;
2. I can make my own medical decisions according to the law of the place I reside;
3. I am not violating any laws where I reside by placing this order;
4. I will use any medication obtained for me from Brocamed Ltd. strictly according to the instructions provided by the physician who prescribed the medication;
5. I am not seeking or relying on any medical information from Brocamed Ltd. and I have consulted a qualified physician licensed where I obtained the prescription within the last year;
6. I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects;
7. I have used the medications for at least 30 days prior this order.

Release and Waiver

I hereby release and save Brocamed Ltd. and its employees and contractors harmless from any and all suits, demands, liabilities, claims, actions, expenses, losses, and damages of any kind whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation arising from:

1. My use of the medication obtained for me by Brocamed Ltd. including, without limitation, any and all side effects whether previously known or unknown;
2. Brocamed Ltd. or its contractors manner or timeliness of completing any actions I have authorized above, including, without limitation, in prescribing the appropriate strength, dosage, or dispensing generic drugs and non-child-protective packaging;
3. My breach of any terms, conditions or representations or warranties in this agreement.

Governing Law

This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of Anguilla B.W.I.

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