VALTREX REFILL WAIVER OF LIABILITY
1. I hereby authorize Medical Wellness 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 Valtrex 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 Valtrex Consultation and/or use of Valtrex.
2. I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Valtrex, and I hereby agree to answer truthfully all of the questions on my questionnaire.
3. I understand that no doctor can guarantee that Valtrex, 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 Valtrex. Complete details of any possible potential side effects associated with Valtrex are listed by Glaxo Wellcome. The most common side effects reported are mild and usually resolve within a short time after one's body adjusts to the medicine: nausea, vomiting, headache, loss of appetite, weakness, stomach pain or dizziness. If they continue to be bothersome or worsen discontinuation of treatment is recommended.
5. I further acknowledge that if I am prescribed Valtrex 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 Valtrex. I understand that the proposed Valtrex 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 taking Valtrex. I understand that there are no data on the safety or effectiveness of Valtrex suppressive therapy for recurrent genital herpes of more than 1 year's duration.
6. I am participating in this Medical Wellness Center Online Valtrex Consultation at my own choice, at my own
expense and my own liability and assume all responsibility for my use of Valtrex. 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 Valtrex 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 Valtrex contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Valtrex.
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 cannot 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 Valtrex or from participating in this program.
10. If after review of my REFILL consultation questionnaire, a physician determines that Valtrex is appropriate
treatment, I hereby authorize a charge of $75.00, plus any processing fees that I agree to, to be
charged to my credit card for this physician consultation. I also understand that if my medical consultation is approved by a Medical Wellness Center physician, there is absolutely NO credit given or cancellations accepted for any reason. Therefore, before submitting consultation request, I must check with any other treating physicians in
regards to treatment.
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 take Valtrex. 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 made the positive diagnosis of genital herpes.
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 Valtrex and pregnant or potentially pregnant woman or nursing women. I understand that although taking Valtrex
may even suppress all future herpes outbreaks and significantly decrease virus shedding and the duration of outbreaks, it does not necessarily have any effect on the transmission of this condition to others. Once you have herpes, the virus always stays in your body and at any time even when you have no active outbreaks you can transmit the virus to a sexual partner. Normal precautions must continue.
13. I have read the contraindications which include any kind of renal impairment, renal disease, dialysis, renal failure, organ transplants, kidney transplants, bone marrow transplants and advanced HIV disease or a compromised immune system. In clinical trials patients with advanced HIV disease or organ transplants had severe reactions including death to high doses of Valtrex. Valtrex 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 outbreaks. Pregnant or potentially pregnant or nursing mothers should not take Valtrex, there are no studies available on the safety of Valtrex under these conditions and Valtrex has been shown to get into breast milk.
14. I understand that there are NO refunds for the online doctor consultation fee to Medical Wellness Center for any
reason. If after submitting the consultation form, I later change my mind for any reason and decide the medication
is not for me there are no refunds. Therefore, always check first with your pharmacy and/or physician to make sure you do not have any contraindications to treatment. If after submitting my consultation I later change my mind and
choose not to fill the prescription I receive or not to use the medication or to discontinue use of the medication for
any reason there are NO refunds. Once submitting the consultation, unless email notification is sent immediately
within 5 minutes of submitting the consultation (email button is on consultation page immediately below the submit button), there is absolutely NO cancellations or NO refunds given for any circumstance.
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 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.