TOPICAL FINASTERIDE REFILL WAIVER OF LIABILITY
1. 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 finasteride Consultation and/or use of topical finasteride.
2. I hereby state that I am an adult MALE age 18 or older, I am aware of any possible side effects of topical finasteride, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that topical finasteride, 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 finasteride. In clinical studies only 1.3% of patients discontinued use due to adverse experiences possibly related to Propecia (vs 0.9% for placebo). Complete details of any possible potential side effects associated with Propecia are listed by Merck (http://www.topical finasteride.com). Side effects are very uncommon and do not affect most men. Less than 2% of men experienced possible sexual side effects such as less desire for sex, decrease amount of semen etc. These side effects disappeared in most men who continued to take Propecia and completely went away in men when stopped taking Propecia.
5. I further acknowledge that if I am prescribed topical finasteride 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 topical finasteride.
6. I am participating in this Medical Wellness Center Online topical finasteride Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of topical finasteride. I acknowledge and agree that I initiated this contact with Medical Wellness 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.
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 topical finasteride 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 finasteride contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take topical finasteride.
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 take topical finasteride or from participating in this program.
10. If after review of my consultation questionnaire, a physician determines that topical finasteride is appropriate treatment, I hereby authorize a charge of $75.00 + $9.50 or $20 Express procesing to be charged to my credit card for this physician consultation.
11. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians.
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 finasteride and pregnant or potentially pregnant woman: pregnant or potentially pregnant women must not be exposed in any way to the active ingredient in topical finasteride and should not even handle or touch topical finasteride solution or pills, especially broken pills.
13. I have read the contraindications which include liver function abnormalities, liver disease, hepatitis or any other medical disorder of liver function including but not limited to cirrhosis, cancer, jaundice etc. topical finasteride is for MALES only, NO woman must ever take topical finasteride under any circumstances. Pregnant or potentially pregnant or nursing mothers must not even touch the topical finasteride solution or Propecia pill especially broken pills. Any absorption of the active ingredient in topical finasteride by skin or swallowing has a high probability of causing abnormalities in a male baby’s sex organs. Contraindicated in anyone under 18 years of age
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.