Consent Form

 

I hereby release Medicine Shoppe Pharmacy #1356 dba Excel Apothecary and all of its employees and contractors including physicians from all liability whatsoever associated or connected with my hormone consultation and/ or use of Bioidentical Hormone Replacement.  I hereby state that I am an adult at least 18 years of age and that I am aware of the potential effects associated with bioidentical hormone replacement.  I hereby agree to answer truthfully all of the necessary questions on my questionnaire.

 

I understand that no doctor, nurse, pharmacy or administrative personnel can guarantee that bioidentical hormone replacement, even if prescribed, will provide the results I seek.   Further, I understand that even if prescribed may suffer adverse effects from bioidentical hormone replacement.   I hereby release The Medicine Shoppe Pharmacy #1356 dba Excel Apothecary, LLC and all of its employees and contractors including physician from any and all liability whatsoever associated with any adverse effects I many suffer from my use of bioidentical hormone replacement. 

 

I am participating in the program at my own choice, at my expense and my own liability and assume all responsible for my use of bioidentical hormone replacement.  I fully understand that it is my responsibility to have a physical examination, including any suggested laboratory tests to ensure that I have no disease(s), which might make bioidentical hormone replacement inappropriate for my condition.

 

I understand the terms and charges for services listed on the consult page, I also understand the charges are due and payable at the time of consult.   

 

I agree that I have read and understand all of the information above

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