Periostat 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 Periostat 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 Periostat Consultation and/or use of Periostat.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Periostat, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Periostat, 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 in general there are no serious adverse reactions on rare occasions one may develop allergic reactions or rare unreported side effects. I understand if prescribed, I may fall into the extremely rare category and suffer adverse effects from Periostat. The most common side effects reported are mild and usually resolve within a short time which are nausea and mild stomach upset. I understand that taking Periostat may make me more sensitive to the sun or tanning bed which could result in sunburn. I understand that if the side effects continue to be bothersome I must seek immediate attention from my regular-treating primary care physician or an emergency medical facility.
5. I further acknowledge that if I am prescribed Periostat 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 Periostat. I understand that the proposed Periostat 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 Periostat. I understand that Periostat must NOT be taken by pregnant or breastfeeding women or women attempting to become pregnant or anyone with Renal or Liver disease, or anyone taking anticoagulant blood-thinning medication.
6. I am participating in this Medical Wellness Center Online Periostat Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Periostat. 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.
7. I fully understand that it is my responsibility to have routine physical examinations to ensure that I have no disease(s) which might make Periostat inappropriate for my condition. I further agree that I have consulted with my physician and dental professional and/or pharmacist and hereby warrant that I do not have any conditions or I am not taking any medications that would make Periostat contraindicated. I further agree to immediately notify any doctor and dental care professional whose present care I am under that I have chosen to take Periostat. 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 and dental professionals 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 Periostat or from participating in this program.
10. If after review of my consultation questionnaire, a physician determines that Periostat is an appropriate treatment, I hereby authorize a charge of $49.95, 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 and agree to continue regular annual or biannual visits to my dental care professional. I understand and agree that Medical Wellness Center recommends a physical examination by a doctor and dental examination before I use Periostat. I understand that an online medical consultation will NOT include an actual physical exam or dental exam. I acknowledge, in order to be eligible for an online consultation that I have been seen by a physician and or dental care professional who has made the positive diagnosis of Periodontal disease.
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 Periostat and pregnant or potentially pregnant woman or nursing women, anyone with Liver or Renal Disease or taking Anticoagulants as well as all the contraindications detailed in contraindication section. I also understand that I must have been diagnosed by my dental professional as having periodontal disease.
13. I understand that taking Periostat may make oral contraceptives less effective. Therefore if I am using birth control pills and taking Periostat I MUST use an additional form of birth control while on Periostat to prevent pregnancy. I am aware that Periostat is a known medication to cross the placenta and causes harm to the developing fetus.
14. 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 decides not to fill the prescription 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 online Physician consultation, you must agree to the “Waiver of Liability” above. By clicking “agree” means that: I have read and understood 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.