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,
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