Aldara Refill WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness Center and any of its physicians, employees, associates, and contractors to perform and undertake an on-line medical consultation and evaluation of me for a potential patient for Aldara treatment. I hereby release Medical Wellness Center and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my Aldara Consultation and/or use of Aldara.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Aldara, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Aldara, even if prescribed, will provide the results I seek. I acknowledge that no guarantees have been made to me as to the results as there is no known medical treatment that gives 100% satisfaction to everyone, nor are there any guarantees against unfavorable results, risks or complications.
4. I understand that although no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from Aldara. The most common side effects reported are mild and usually resolve within a short time and are usually local skin reactions such as erythema, redness, erosion, flaking and edema, swelling of the area, mild irritation at site of application. If they continue to be bothersome or worsen discontinuation of treatment is recommended for several days, wash the area with mild soap and water. When skin reaction has subsided Aldara treatment may be resumed. If irritation progresses or does not resolve you must seek immediate attention from you regular-treating primary care physician.
5. I further acknowledge that if I am prescribed Aldara by Medical Wellness Center, I have full knowledge that no physician, nurse or medical personnel can predict as whether I would or would not have any adverse effects since every individual has a unique biological/chemical make-up. I understand that all possible risks and/or complications do not need to be explained to me, nor do I consider this practical or even possible because risks and complications may occur that have never been recorded before. I hereby release Medical Wellness Center and any associated physicians from any and all liability whatsoever with any adverse effects I may suffer from my use of Aldara. I understand that the proposed Aldara treatment may involve risks and possibilities of complications that may occur in patients even when the utmost care, judgment, and skill are used. I acknowledge that there are no guarantees made to me as to favorable or unfavorable results not against risks or complications. I accept and fully understand the risks known and unknown of any proposed medical treatment and accept the risk of substantial and serious harm and/or complication even to the loss of bodily functions and /or life itself from using Aldara. I understand that there are no data on the safety or effectiveness of Aldara therapy in immunosuppressed adults, and its safety has NOT been determined in pregnant or breast-feeding adults.
6. I am participating in this Medical Wellness Center Online Aldara Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Aldara. I acknowledge and agree that I initiated this contact with Medical Wellness Center, and I agree that all on-line medical consultations and treatments will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine which may be in another state from my own.
7. I fully understand that it is my responsibility to have routine physical examination to ensure that I have no disease(s) which might make Aldara inappropriate for my condition. I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I do not have any conditions or I am not taking any medications that would make Aldara contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Aldara. I understand that if at some time after I submit a medical consultation and I either change my mind about taking the medication or another treating doctor recommends I do not use the medication, I do not have to fill the prescription, but the cost of the medical consultation is NON-refundable if approved by a Medical Wellness Center Physician. Therefore, always check with your primary-care physician first before submitting the medical consultation.
8. I further understand that not answering truthfully to any of the medical consultation questions or falsifying information in order to obtain prescription medication is a violation of both State and Federal U.S. law. I hereby agree to answer all questions on medical consultation truthfully.
9. I understand that if I have failed in any way to provide Medical Wellness Center with my complete and accurate medical history or if I fail to notify Medical Wellness Center of any changes in the future, then I can not hold Medical Wellness Center or its physicians responsible for any adverse effects I may suffer and I am solely responsible for any adverse effects I may suffer from taking or continuing to use Aldara or from participating in this program.
10. If after review of my consultation questionnaire, a physician determines that Aldara is appropriate treatment, I hereby authorize a charge of $75.00, plus any shipping & handling charges that I agree to, to be charged to my credit card for this physician consultation. ( If not approved there is NO charge to the credit card.) I also understand that if my medical consultation is approved by a Medical Wellness Center Physician, there is absolutely NO credit given or cancellations for any reason or if I choose not to use the prescription medication.
11. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians. I understand and agree that Medical Wellness Center recommends a physical examination by a doctor before I use Aldara. I understand that an on-line medical consultation will NOT include an actual physical exam. I acknowledge, in order to be eligible for an on-line consultation that I have been seen by a physician who has made the positive diagnosis of recurrent genital warts. It is imperative to be diagnosed by a physical exam by a physician as genital warts can be confused with other conditions such as Squamous Cell Carinoma.
12. Also, I agree that if approved the medication will be used only by the person for whom prescribed, and I will not give medication or prescription to another party. I also understand the contraindications and warnings regarding Aldara and pregnant or potentially pregnant woman or nursing women, severely immune-compromised patients and patients with advanced HIV disease. I also understand the necessary precautions if I am an uncircumcised male. I understand that although taking Aldara may significantly clear up genital warts, it does not necessarily have any effect on the transmission of this condition to others. Once you have the Human Papillomavirus, the virus may always stay in your body and at any time even when you have no active outbreaks you can transmit the virus by physical -sexual contact. Normal precautions must continue.
13. I also understand that the use of Aldara cream can weaken condoms and vaginal diaphragms. Therefore, concurrent use is NOT recommended.
14. I have read the relative – contraindications which include advanced HIV disease or a compromised immune system, concurrent use of other topical medication to the genital area, and pregnancy or nursing. Aldara is for adults (age 18 or older) only who have been positively diagnosed by a physical visit to a physician to suffer from genital warts. Aldara is NOT to be used for internal warts on the cervical area, vagina, inside the rectum or urethra on mucous membranes, in or near the eyes, nor for genital herpes. Aldara is only to be applied externally (topically) to the genital and perianal area as directed. Pregnant or potentially pregnant or nursing mothers should not use Aldara, there are no studies available on the safety of Aldara under these conditions and whether Aldara gets into breast milk.
15. I also understand that Medical Wellness Center is unable to accept any requests for cancellations or refunds for any medical consultations once submitted. There are NO refunds given ever if a patient for any reason after receiving approval of the medical consultation changes their mind and decides not to take the drug or has a change in their medical conditions or upon another doctor’s opinion no longer desires the drug. There are no refunds given for the medical consultation service of one of our physicians reviewing and acting upon the medical consultation submitted.
In order to be eligible for an online Physician consultation, you must agree to the “Waiver of Liability” above. By clicking “agree” means that: I have read and understand the above referenced Medical Wellness Center’s Waiver of Liability and authorize and accept the proposed terms and I declare that I understand the risks. I declare that I have answered all questions truthfully and accurately. I understand that by “clicking I Agree” electronically constitutes the equivalent of my signature upon a binding agreement between Medical Wellness Center and myself.