Renova Tretinoin Refill WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness Center’s Anti-Aging Medical Skin Care Center 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 RENOVA treatment. I hereby release Medical Wellness Center’s Anti-Aging Medical Skin Care Center and all of its employees and contractors including physicians from any and all liability whatsoever associated or connected with my RENOVA Consultation and/or use of RENOVA.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of RENOVA, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that RENOVA, 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 RENOVA has been approved by the FDA for the treatment of sun damaged skin, RENOVA has not been shown to have any mitigating effect on significant signs of chronic sun exposure such as course or deep wrinkling, skin yellowing, lentigines, telangiectasia, skin laxity, keratinocytic atypia, melanocytic atypia or dermal elastosis. While it will not repair sun damaged skin, eliminate wrinkles, or reverse the aging process, it is proven to reduce wrinkles, fade brown spots and smooth surface roughness.
4. I understand that although no serious adverse reactions have been reported to date, even if prescribed, I may suffer adverse effects from RENOVA. Click here for complete details of any possible potential side effects associated with RENOVA. The most common side effects reported are mild and usually resolve within a several weeks. The majority of patients experience some self-limited local reaction: local erythema (redness), pruritis (itching), burning, stinging, peeling and blistering at site of application. If these local irritations do not resolve and continue to be bothersome or worsen discontinuation of treatment is recommended and one should seek immediate medical attention from one’s personal physician.
5. I further acknowledge that if I am prescribed RENOVA by Anti-Aging Medical Skin Care 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 -Anti-Aging Medical Skin Care Center and any associated physicians from any and all liability whatsoever with any adverse effects I may suffer from my use of RENOVA. I understand that the proposed RENOVA 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 RENOVA. 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: at 100- 200 times the human recommended dose a few skin tumors in female mice and liver tumors in male mice were observed. RENOVA is a dermal/skin irritant and the results of continued irritation of the skin for greater than 48 weeks in chronic , long term use are not known. There is evidence of atypical changes in melanocytes and keratinocytes, and of increased dermal elastosis in some patients treated with RENOVA for longer than 48 weeks. The significance of these findings is unknown.
6. I understand that there are no data on the safety or effectiveness of RENOVA therapy in adults over age 50 or after 48 months of continuous use, and its safety has NOT been determined in pregnant or breast-feeding adults and is not to be used by individuals with moderately or heavily pigmented skin. Oral tretinoin( the active ingredient in RENOVA) has been shown to be teratogenic (having effect on unborn fetuses) in animals at extremely high doses, and the teratogenic effects of topical tretinoin n not established. Therefore RENOVA is CONTRAINDICATED during pregnancy, if one is trying to get pregnant, and while breast feeding.
7. I am participating in this Medical Wellness Center ‘s Anti-Aging Medical Skin Care Center Online RENOVA Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of RENOVA. I acknowledge and agree that I initiated this contact with Medical Wellness Center’s Anti-Aging Medical Skin Care 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 examination to ensure that I have no disease(s) which might make RENOVA 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 RENOVA contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take RENOVA. 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 Anti-Aging Medical Skin Care 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.
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 RENOVA or from participating in this program.
11. If after review of my consultation questionnaire, a physician determines that RENOVA 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 Anti-Aging Skin Care Physician, there is absolutely NO credit or refunds given or cancellations for any reason or if I choose not to use the prescription medication.
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 Anti-Aging Medical Skin Care Center recommends a physical examination by a doctor before I use RENOVA. 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 RENOVA.
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 RENOVA and pregnant or potentially pregnant woman or nursing women.
14. I have read the contraindications which include but not limited to any kind of medications containing sulfa, Retin-A or vitamin A drugs, Retinol or Accutane or any medications that are known photosensitizers such as thiazide diuretics, tetracyclines or fluoroquinolones antibiotics, phenothiazines, sulfonamides. Check with your personal physicians &/or pharmacist about medications currently taking. Always inform your Physician your are using RENOVA before being prescribed any medications. and advanced HIV disease or a compromised immune system. RENOVA is for adults (age 18 or older) who have NO preexisting skin disease, actinic keratosis, eczema or history of skin cancer. RENOVA is NOT to be used on mucous membranes, in or near the eyes, or in the angles of the nasal area. RENOVA is only to be applied externally (topically) to face area as directed. Pregnant or potentially pregnant or nursing mothers should not use RENOVA, there are no studies available on the safety of RENOVA under these conditions and whether RENOVA gets into breast milk.
15. I also understand that Medical Wellness Center Anti-Aging Medical Skin Care 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 receiving approval of the medical consultation, changes their mind and decides not to use RENOVA 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. Also no refunds can be given for any SkinCeutical Physician-grade Skin Care Products nor can any guarantees be made as to their efficacy in any particular individual. For any concerns regarding SkinCeutical Products please contact them directly.
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 RENOVA and authorize and accept the proposed terms. I declare that I understand the potential risks associated with RENOVA treatment. I understand that by “clicking I Agree” electronically constitutes the equivalent of my signature upon a binding agreement between Medical Wellness Center Anti-Aging Medical Skin Care Center and myself.