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 Zovirax (acyclovir)
cream 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 Zovirax (acyclovir)
cream Consultation and/or use of Zovirax (acyclovir) cream.
2. I hereby state that I
am an adult age 18 or older, I am aware of any possible side effects
of Zovirax (acyclovir) cream, and I hereby agree to answer truthfully all
of the questions on my questionnaire.
3. I understand that no
doctor can guarantee that Zovirax (acyclovir) cream, 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 Zovirax (acyclovir) cream. Complete
details of any possible potential side effects associated with Zovirax
(acyclovir) cream at http://www.Zovirax (acyclovir) cream.com. 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 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 Zovirax (acyclovir) cream 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 Zovirax (acyclovir) cream. I understand that the proposed
Zovirax (acyclovir) cream 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 Zovirax (acyclovir) cream. I understand
that there are no data on the safety or effectiveness of Zovirax
(acyclovir) cream 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 Zovirax (acyclovir) cream Consultation
at my own choice, at my own expense and my own liability and assume all
responsibility for my use of Zovirax (acyclovir) cream. 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 Zovirax (acyclovir) cream
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 Zovirax (acyclovir)
cream contraindicated. I further agree to immediately notify any doctor
whose present care I am under that I have chosen to take Zovirax (acyclovir)
cream. 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 Zovirax (acyclovir) cream or from participating
in this program.
10. If after review of my consultation
questionnaire, a physician determines that Zovirax (acyclovir) cream
is appropriate treatment, I hereby authorize a charge of $49.95,
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 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 Zovirax
(acyclovir) cream. 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 recurrent 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 Zovirax (acyclovir) cream
and pregnant or potentially pregnant woman or nursing women. I understand
that although taking Zovirax (acyclovir) cream may significantly shorten
the duration of a cold sore outbreak to 4 days from the usual 10 days,
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.
Zovirax (acyclovir) cream is for adults (age 18 or older) only
who have been positively diagnosed by a physical visit to a physician to
suffer from recurrent cold sore outbreaks. Zovirax (acyclovir) cream
is NOT to be used for canker sores (sores inside the mouth), on mucous
membranes, in or near the eyes, nor for genital herpes. Zovirax (acyclovir)
cream is only to be applied externally (topically) to the lips and face
area as directed. Pregnant or potentially pregnant or nursing mothers should
not use Zovirax (acyclovir) cream, there are no studies available on the
safety of Zovirax (acyclovir) cream under these conditions and whether
Zovirax (acyclovir) cream 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 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. |