PLENITY REFILL WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness Center and any of its physicians, employees and contractors to perform and undertake an online telemedicine medical consultation and evaluation of me for a potential Plenity weight loss patient. 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 Plenity Consultation and/or use of Plenity.
2. I hereby state that I am an adult age 22 or older, I am aware of the contraindications, precautions, and any possible side effects of Plenity. I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Plenity, 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 no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from Plenity. The most common, but rare, side effects are diarrhea, distended abdomen, infrequent bowel movements, and flatulence. These reactions are usually mild and transient and do not indicate stopping therapy.
5. I further acknowledge that if I am prescribed Plenity by Medical Wellness Center, I have full knowledge that no physician, nurse, or medical personnel can predict as to 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 Plenity.
6. I am participating in this Medical Wellness Center program at my own choice, at my own expense, and my own liability and assume all responsibility for my use of Plenity. 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 examination to ensure that I have no disease(s) which might make Plenity 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 Plenity contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Plenity.
8. I further understand that it is recommended if I am taking any medication that has to be taken with food, Plenity may alter the absorption of these medications.
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. I am solely responsible for any adverse effects I may suffer from taking or continuing to take Plenity or from participating in this program.
10. If after review of my consultation questionnaire, a physician determines that Plenity is an appropriate treatment, I hereby authorize a one-time charge of $75.00 for a Refill consult plus processing fee (totaling either $84.50 regular service or $95 Express 24 hour service) 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 refunds given or cancellations accepted for any reason even if another physician renders a different opinion and recommends that you not use the medication. Therefore, before submitting a consultation, you should check first with any other treating physicians in regards to your use of Plenity. If after submitting my consultation, I later change my mind and choose not to fill the prescription for any reason including cost or not to use the medication or discontinue use of the medication for any reason, there are NO refunds. Once submitting the consultation, unless email notification is send immediately within 5 minutes of submitting the consultation, there are absolutely NO cancellations or no refunds given for any circumstance (email: email@example.com)
11. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians.
12. I hereby understand that I must continue with my regular health care visits to my own physician and that I must inform all treating physicians as well as my primary care physician that I am taking Plenity.
13. I fully understand that being overweight puts me at increase risk for many diseases, one of which is gall bladder disease. While losing weight the risk of suffering from gall bladder disease may increase as high as 38%. I acknowledge that I have been fully warned about this possible outcome which is the development of gall bladder disease, gall stones and possibly necessitating removal of the gall bladder.
14. I have read the contraindications which are pregnant or nursing women, a history of intestinal malabsorptions syndromes, esophageal or GI anatomic anomalies such as webs, strictures, diverticuli, rings, Chron’s Disease, Ulcerative colitis, gastric ulcers, past surgery that affects GI transit and motility, past bariatric surgery including gastric bypass, gastric sleeve, gastric band etc, stomach or colon cancer, colostomy bag, and those currently suffering from anorexia nervosa or bulimia. Also, those with active GI conditions such as reflux (GERD) or heartburn need to exercise caution with Plenity.
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 understood the above referenced 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.