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
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
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.