Jublia Refill WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness Center’s 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 Jublia 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 Jublia Consultation and/or use of Jublia .
2. I hereby state that I am an adult age 18 or older, I have read and am aware of any possible side effects of Jublia and contraindications to Jublia use. I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Jublia , 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 Jublia has been approved by the FDA for the treatment of mild to moderate nail fungal infections in immunocompetent adults, Jublia may not be effective in everyone and nail fungal infections tend to recur.
4. I understand that although no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from Jublia . The most common side effects reported in about 5% of users are mild and usually resolve within a several weeks. There are no known systemic side effects when used as directed and side effects are limited to mild local redness and swelling at application site.
5. I further acknowledge that if I am prescribed Jublia 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 Jublia . I understand that the proposed Jublia 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 Jublia . 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 clear because of the high dosages tested in mice.
6. I understand that there are no data on the safety or effectiveness of Jublia therapy pregnant and or breast feeding adults. Jublia is a Category C drug in regards to pregnancy. Therefore Jublia is CONTRAINDICATED during pregnancy and while breast feeding.
7. I am participating in this Medical Wellness Center ‘s Online Jublia Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Jublia . 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. I am seeking a consultation through the Internet instead of making an appointment with my regular primary care physician at this time because this site is more convenient or for other personal reasons.
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 Jublia 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 Jublia contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Jublia . 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’s 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. The consulting physician relies on my responses in making a decision and therefore I understand that I must answer each question truthfully and accurately. I understand that failure to do so on my part to provide truthful and accurate information on the physician consultation could result in the physician making a treatment decision that is hazardous to my physical or mental condition.
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 Jublia or from participating in this program.
11. If after review of my consultation questionnaire, a physician determines that Jublia 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’s Physician, there is absolutely NO credit or refunds given or cancellations for any reason or if I choose not fill the prescription or I choose not to use the prescription medication for any reason.
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 Jublia . 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 Jublia . I understand that the online consulting physician is not my primary care physician and I am under the care of a primary care physician. I am NOT relying on the online consulting physician for primary care. I will NOT rely or substitute the advice given by the online consulting physician when it contradicts the advice of my primary care physician. I will NOT make a claim that the consulting physician acted unprofessionally or below the standard of care solely because the physician did not perform a physical examination on me. I hereby release Medical Wellness Center and any consulting physicians from all claims that the consulting physician acted unprofessionally or below the standard of care solely because the physician did not perform a physical examination on me.
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 Jublia and pregnant woman or nursing women. I agree to use the medication as directed only.
14. I have read the contraindications. Always check with your personal physicians &/or pharmacist about medications currently taking. There is no studies on drug interactions of Jublia and other topical medications. Always inform your Physician your are using Jublia before being prescribed any medications. Jublia is NOT to be used on mucous membranes, in or near the eyes, or in the vaginal area. Jublia is only to be applied externally (topically) to the infected toenail or toenails and to the immediately adjacent skin only. Pregnant or nursing mothers should not use Jublia , there are no studies available on the safety of Jublia under these conditions and whether Jublia 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 submitting the medical consultation, changes his or her mind and decides not to fill the prescription or decides not to use Jublia or has a change in his or her 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 Jublia and authorize and accept the proposed terms. I declare that I have answered all questions truthfully and accurately. I declare that I understand the potential risks associated with Jublia treatment. I understand that by “clicking I Agree” electronically constitutes the equivalent of my signature upon a binding agreement between Medical Wellness Center and myself.