Latisse (bimatoprost) Hair Loss WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness Center and any of its physicians, employees, associates, and contractors to perform and undertake an online medical consultation and evaluation of me for a potential patient for Latisse (bimatoprost) treatment for male pattern hair loss/ baldness. 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 Latisse (bimatoprost) Consultation and/or use of Latisse (bimatoprost).
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Latisse (bimatoprost), and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Latisse (bimatoprost), 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 Latisse (bimatoprost) has passed Phase I FDA safety trials, but it being prescribed off-label for male pattern hair loss.
4. I understand that although no serious adverse reactions have been reported to date, I may suffer adverse effects from Latisse (bimatoprost). Side effects are very uncommon. Side effects are eye redness and discoloration of skin. Uncommon side effects can be darkening of the skin which should reverse with cessation of medication. Not reported with Latisse (bimatoprost), but when the same active ingredient, bimatoprost, is used in the eye itself for glaucoma, permanent darkening of the iris of the eye has been reported.
5. I understand that although in general there are no serious adverse reactions on rare occasions one may develop allergic reactions or rare unreported side. I understand that the proposed treatment with Latisse (bimatoprost) may involve risks and possibilities of complications that may occur in patients even when the utmost care, judgment, and skills are used. I acknowledge that there are no guarantees made to me as to favorable or unfavorable results. I accept and fully understand the risks known and unknown 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 Latisse (bimatoprost).
6. I further acknowledge that if I am prescribed Latisse (bimatoprost) 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 Latisse (bimatoprost).
7. I am participating in this Medical Wellness Center Online Latisse (bimatoprost) Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Latisse (bimatoprost). 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 examinations to ensure that I have no disease(s) which might make Latisse (bimatoprost) 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 Latisse (bimatoprost) contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Latisse (bimatoprost).
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 take Latisse (bimatoprost) or from participating in this program.
11. If after a review of my consultation questionnaire, a physician determines that Latisse (bimatoprost) is the appropriate treatment, I hereby authorize a charge of $49.95 plus either $10.30 Regular or $20 Express processing fees 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 accepted for any reason even if another physician renders a different opinion and recommends not to use the medication. Therefore before submitting a consultation request, I must check with any other treating physicians in regards to treatment. If after submitting my consultation I later change my mind and choose not to fill the written prescription I receive or not to use the medication or to discontinue use of the medication for any reason there are NO refunds. Once submitting the consultation, unless email notification is sent immediately within 5 minutes of submitting the consultation (email button is on consultation page immediately below the submit button), there are absolutely NO cancellations or NO refunds given for any circumstance.
12. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians.
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 Latisse (bimatoprost). I understand there has not been adequate testing of Latisse (bimatoprost) in pregnant and lactating women to guarantee safety. Therefore Latisse (bimatoprost) must NOT be used if you are pregnant or breastfeeding.
14. I have read the contraindications which allergies to any of the ingredients in Latisse (bimatoprost), bimatoprost, or sensitivity to Prostaglandin analogs. Do not use Latisse (bimatoprost) if using LUMIGAN, Xalatan or Travatan or other Prostaglandin analogs for glaucoma eye drops in your eye. Contraindicated in anyone under 18 years of age.
15. I understand that Latisse (bimatoprost) is for EXTERNAL use ONLY. I must not put Latisse (bimatoprost) in the eye or on the lower lids or take it internally.
16. I understand that Medial Wellness Center is unable to accept any requests for cancellations or refunds for any reason once submitted. There are no refunds given even if one changes one’s mind for any reason, has a change in one’s medical condition or upon the advice of another physician no longer desires the drug. It is your responsibility to check the price of the actual medication with pharmacies before submitting the consult. Insurance most likely will NOT cover the cost of this medication, and we will not contact your pharmacy in regards to prior authorizations for insurance coverage because we are prescribing this for cosmetic and not medical necessary reasons. There are no refunds for the consult if you decide the actual medication is too expensive and you do not fill the prescription. One does not have to fill the prescription or take the medication, but there are NO refunds for the online consultation service.
In order to be eligible for 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.