PRESCRIPTION MEDICATION CONSENT FORM

AND RELEASE FROM LIABILITY

PRESCRIPTION MEDICATION CONSENT FORM

AND RELEASE FROM LIABILITY
Your First Name
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Your Last Name
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Select a date of birth
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Your Phone number
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Your E-mail Address
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Your Address
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  • - select a state -
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Zipcode
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City
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Current Medication
Are you taking any current medication?
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If Yes
Let us know what the current medication are for.
Leave the field blank if you don't take any other medication
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Are you allergic to any medication that you know off?
e.g. Doxycycline or Azithromycin
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If Yes
explain your allergies
Leave the field blank if no allergies
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Are you PREGNANT or LACTATING?
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Pharmacy Name:
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Pharmacy Phone number:
Invalid phonenumber!
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Self Declaration
I hereby certify that the answers given by me to the above questions are true and complete to the best of my knowledge and I have read and understand them. I have had an opportunity to ask questions that were answered to my satisfaction and wish to receive the medication being prescribed to me.

Furthermore, I hereby release and forever discharge for myself, my heirs, executors, administrators and assignees, 24/7 Labs and their employees, owners and representatives, from any and all claims, demands, actions and causes of action which may or could result from receiving the medication prescribed.
Declaration
Your personal information and any results shall be held strictly confidential. I understand that 24/7 Labs is not a Medicare or Medicaid participating provider. Insurance will not be billed; however, forms and receipts may be made available to me in order for me to request possible reimbursement from any other third party. Third parties include, but are not limited to, insurance companies, employers or other entities that may provide benefits for any type of healthcare reimbursement.
By Clicking on Submit you agree to all the declarations and policies of the company as has bene mentioned on the website,
Sign here
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Happy Stories

Laith Zkaria
Laith Zkaria
2021-04-07
Had an amazing service and fast result with affordable price Highly recommended for any travelers
Lerys Carrasquel
Lerys Carrasquel
2021-04-06
Me encanta el método de enseñanza que usó la señora Maria súper didáctica y profesional. 😍
Diana Serna
Diana Serna
2021-04-06
Excelente aprendizaje , y su personal magnífico súper recomendado
Kayla H
Kayla H
2021-03-23
Great staff with a quick and painless experience! It was nice that I was able to go after 5:00pm. Highly recommend this facility!
stanley linthicum
stanley linthicum
2021-03-19
Very detailed and they actually want to help their patients find long term solutions. Mr. Carlos is a great mind with a rare trait of going the extra mile to help patients. Highly recommend!
Melissa Murillo
Melissa Murillo
2021-03-17
Neraida Fernandez
Neraida Fernandez
2021-03-17
Personas muy amables y muy buenos precios..lugar fantástico
Solanch Coca
Solanch Coca
2021-03-10
Recomiendo este lugar rápido y asequible,,100 % buena atención encantada
Carlos Harrell
Carlos Harrell
2021-03-08
I recommend this clinic, they take real good care of you.
D S
D S
2021-02-27
The employees make this place!! Herman was the best. That guy is hilarious. I was so tired. I came straight from a 11hr flight to get lab work done. He had me laughing so hard i forgot about the 11 hrs flight and difficult Covid ICU shift. I cant say enough about him. And kacey was so helpful and polite as well. Really truly recommend this place for labs or a good laugh.
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