Differin 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 Differin® treatment. I hereby release Medical Wellness Center’s and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my Differin® Consultation and/or use of Differin®.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Differin®, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Differin®, 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. I understand that although taking Differin® has been approved by the FDA for the treatment of acne, Differin® is not a cure for acne and must be used consistently to conrol acne outbreaks. I understand that Differin® is approved for mild to moderate acne vulgaris -Grade I – Grade III and is NOT approved to treat severe cystic acne Grade IV.
4. I understand that although no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from Differin®. Click here for complete details of any possible potential side effects associated with Differin®. The most common side effects reported are mild and usually resolve within a several weeks. The majority of patients experience some self-limited local reaction: local erythema (redness), pruritis (itching), burning, stinging, peeling and increase acne flare-up at site of application. If these local irritations do not resolve and continue to be bothersome or worsen discontinuation or decreased frequency of treatment is recommended. If one experiences blistering and crusting, one should discontinue use and seek immediate medical attention from one’s personal physician.
5. I further acknowledge that if I am prescribed Differin® 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 Differin®. I understand that the proposed Differin® 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 nor 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 Differin®. The effect of long term use and carcinogenesis or mutagensis is not fully determined and the biological significance of animal laboratory results for humans is not always clear because of the high dosages. Pharmacological studies have shown an increase risk of skin neoplasms with similar drugs when exposed to sunlight. The significance of these findings is unknown.
6. I understand that there are no data on the safety or effectiveness of Differin® therapy in children less than 12 years old, and its safety has NOT been determined in pregnant or breast-feeding adults and is not to be used by individuals with chronic skin diseases such as eczema, sebborheic dermatitis. Oral adapalene( the active ingredient in Differin®) has been shown to be teratogenic (having effect on unborn fetuses) in animals at extremely high doses, and the teratogenic effects of topical aldalpene is not fully established. Therefore Differin® is CONTRAINDICATED during pregnancy, if one is trying to get pregnant, and while breast feeding.
7. I am participating in this Medical Wellness Center ‘s Online Differin® Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Differin®. 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.
8. I fully understand that it is my responsibility to have routine physical examination to ensure that I have no disease(s) which might make Differin® 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 Differin® contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Differin®. 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.
9. 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.
10. 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 Differin® or from participating in this program.
11. If after review of my consultation questionnaire, a physician determines that Differin® 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, there is absolutely NO credit or refunds given or cancellations for any reason or if I choose not to use the prescription medication.
12. 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 Differin®. 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 approved my use of Differin®.
13. 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 Differin® and pregnant or potentially pregnant woman or nursing women.
14. I have read the contraindications which include but not limited to any kind of topical medications containing sulfa, resorcinol or salicylic acid, Retin-A or vitamin A drugs, retinoids, Accutane, Retinol or Accutane. Check with your personal physicians &/or pharmacist about medications currently taking. Always inform your Physician your are using Differin® before being prescribed any medications. Differin® is for adults (age 18 or older) who have NO preexisting skin disease, sebborrheic dermatitis, or eczema. Differin® is NOT to be used on mucous membranes, in or near the eyes, or in the angles of the nasal area. Differin® is only to be applied externally (topically) to face and other areas affected by the acne as directed. Pregnant or potentially pregnant or nursing mothers should not use Differin®, there are no studies available on the safety of Differin® under these conditions and whether Differin® 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 even if a patient, for any reason after receiving approval of the medical consultation, changes their mind and decides not to use Differin® 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 Waiver of Liability and I have read and understand the contraindications and warnings associated with Differin® and authorize and accept the proposed terms. I declare that I understand the potential risks associated with Differin® treatment. I understand that by “clicking I Agree” electronically constitutes the equivalent of my signature upon a binding agreement between Medical Wellness Center Anti-Aging Medical Skin Care Center and myself.