TOPICAL ACYCLOVIR 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 Topical Acyclovir 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 Topical Acyclovir Consultation and/or use of Topical Acyclovir.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Topical Acyclovir, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Topical Acyclovir, 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 Topical Acyclovir. The most common side effects reported are mild and usually resolve within a short time: nausea, vomiting, headache, loss of headaches, and mild irritation at the site of application. If they continue to be bothersome or worsen discontinuation of treatment is recommended.
5. I further acknowledge that if I am prescribed Topical Acyclovir 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 Topical Acyclovir. I understand that the proposed Topical Acyclovir 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 Topical Acyclovir. I understand that there are no data on the safety or effectiveness of Topical Acyclovir therapy in immunosuppressed adults, and its safety has NOT been determined in pregnant or breast-feeding adults.
6. I am participating in this Medical Wellness Center Online Topical Acyclovir Consultation at my own choice, at my own expense, and my own liability and assume all responsibility for my use of Topical Acyclovir. 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 Topical Acyclovir 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 Topical Acyclovir contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Topical Acyclovir. 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. There, always check with your primary care physician 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 Topical Acyclovir or from participating in this program.
10. If after review of my consultation questionnaire, a physician determines that Topical Acyclovir is the appropriate treatment, I hereby authorize a charge of $49.95, plus processing fees 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. I understand and agree that Medical Wellness Center recommends a physical examination by a doctor before I use Topical Acyclovir. I understand that an online medical consultation will NOT include an actual physical exam. I acknowledge, in order to be eligible for an online consultation that I have been seen by a physician who has made the positive diagnosis of recurrent genital herpes or cold sores.
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 Topical Acyclovir and pregnant or potentially pregnant women or nursing women. I understand that although taking Topical Acyclovir may significantly shorten the duration of genital herpes or cold sore outbreak, it does not necessarily have any effect on the transmission of this condition to others. Once you have herpes simplex I, the virus always stays in your body, and at any time even when you have no active outbreaks you can transmit the virus by casual physical contact. Normal precautions must continue.
13. I have read the contraindications which include any kind of, organ transplants, kidney transplants, bone marrow transplants, and advanced HIV disease or a compromised immune system. Topical Acyclovir is for adults (age 18 or older) only who have been positively diagnosed by a physical visit to a physician to suffer from recurrent genital herpes or cold sore outbreaks. Topical Acyclovir is NOT to be used for canker sores (sores inside the mouth), on mucous membranes, in or near the eyes, nor for genital herpes. Topical Acyclovir is only to be applied externally (topically) to the affected genital area or to the lips and face area as directed. Pregnant or potentially pregnant or nursing mothers should not use Topical Acyclovir, there are no studies available on the safety of Topical Acyclovir under these conditions and whether Topical Acyclovir gets into breast milk.
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 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 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.