LOW DOSE ORAL MINOXIDIL 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 online medical consultation and evaluation of me for a potential patient for low dose Oral Minoxidil treatment for Male pattern hair loss. 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 Oral Minoxidil Consultation and/or use of Minoxidil.
2. I understand that only topical minoxidil is FDA-approved for hair loss. I further understand that although oral minoxidil is FDA-approved for high blood pressure, it is not approved for hair loss. Therefore, I acknowledge that I am being prescribed low-dose oral minoxidil “off-label” for male pattern hair loss. In contrast to oral minoxidil dose of 10-40 mg daily for hypertension, low-dose oral minoxidil for hair loss is a maximum of 2.5mg daily.
3. I hereby state that I am an adult MALE age 18 or older, I am aware of any possible side effects of Minoxidil, and I hereby agree to answer truthfully all of the questions on my questionnaire.
4. I understand that no doctor can guarantee that Minoxidil, 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.
5. I understand that although low dose oral minoxidil is not commonly associated with major side effects, I may suffer adverse effects from Minoxidil. Studies show that less than 5% of men have had to stop treatment because of side effects.
6. The most common side effect occurring in about 15% of users is hypertrichosis, increased hair growth on face and body. Usually within one to six months after stopping treatment, this excess hair growth reverses. Another common temporary side effect is increases shedding in the first 4 -12 weeks of treatment
7. The following are some of the systemic side effects which can occur in about 5.5% of patients: lightheadedness, low blood pressure, dizziness, palpitations, increased heart rate, fluid retention, ankle and leg swelling, swelling around eyes, headaches, rashes, itching and rarely pericarditis, breast tenderness and insomnia.
8. *** If you experience new or increased chest pain, shortness of breath, sudden changes to vision or hearing or very severe heartburn, seek immediate emergency medical care.
9. I understand that although in general serious adverse reactions are rare, one may develop allergic reactions or rare unreported side effects. 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 oral and/or topical Minoxidil.
10. I further acknowledge that if I am prescribed low dose Oral Minoxidil 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 Minoxidil.
11. I am participating in this Medical Wellness Center Online Minoxidil Consultation at my own choice, at my own expense, and my own liability and assume all responsibility for my use of Minoxidil. I acknowledge and agree that I initiated this contact with Medical Wellness Center, and I agree that all online 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.
12. I fully understand that it is my responsibility to have routine physical examinations to ensure that I have no disease(s) which might make Minoxidil 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 low dose oral Minoxidil contraindicated. Low dose oral Minoxidil is contraindicated in the following conditions: heart disease, arrhythmia, afib, liver disease, kidney disease, high blood pressure, orthostatic hypotension, history of stroke, peripheral edema, pulmonary hypertension with mitral stensosis, Porphyria and Pheochromocytoma and in pregnant or breast feading women or anyone under the age of 18. I further agree to immediately notify any doctor whose present care I am under that I have chosen to use Minoxidil.
13. 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.
14. 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 low dose Oral Minoxidil or from participating in this program.
15. If after a review of my consultation questionnaire, a physician determines that low dose Oral Minoxidil is appropriate treatment, I hereby authorize a charge of $75.00 + $9.50 regular processing fee or $20 Express fee to be charged to my credit card for this physician consultation for a six month prescription. 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 prescription and order the medication 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 is absolutely NO cancellations or NO refunds given for any circumstance.
16. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians.
17. 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 Minoxidil women and pregnant or potentially pregnant women.
18. I have read the contraindications to low dose Oral Minoxidil treatment and understand the contraindications. Minoxidil is prescribed Online for MALES only for Male pattern baldness. Male pattern hair loss or androgenic hair thinning in women could be due to life-threatening underlying conditions and must be treated by a physician who has physical contact and examines the patient and rules out diseases. Contraindicated in anyone under 18 years of age.
19. 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. 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 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.