If Yes
Let us know what the current medication are for.
Leave the field blank if you don't take any other medication
Field is required!
Field is required!
If Yes
explain your allergies
Leave the field blank if no allergies
Field is required!
Field is required!
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.
