Consent & Release Agreement
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Consent
Portage Pharmacy (“Pharmacy”) offers consultations with respect to hormonal evaluation, weight management, and nutritional consulting and provides certain related tests (“Services”). A Pharmacy representative has explained to me the nature of the Services I have asked to receive, which are specified in the questionnaire, the goals I hope to achieve with the help of the Pharmacy’s Services, and some of the possible risks.
I understand that making recommendations regarding health matters is not an exact science and that the Pharmacy makes no guarantee that I will be able to achieve the goals I seek or avoid any particular risks. I understand that the Pharmacy is not engaged in the practice of medicine and it is my responsibility to seek the advice of my physician before acting on recommendations provided by the Pharmacy. I understand that the personal and medical history I provide to the Pharmacy and the Pharmacy’s evaluation of my health status is done to help me achieve my individualized goals and is not intended to identify specific health problems I may have and is not a substitute for a physician’s examination. I understand it is my responsibility to provide complete and accurate information to the Pharmacy and to inform the Pharmacy about physical or mental conditions that may affect the Services and that my failure to do so could adversely affect my health, the Pharmacy’s recommendations and my ability to achieve my individualized goals.
The data and/or results derived from the Services are to be considered preliminary only. Test results are in no way conclusive and do not constitute a diagnosis of any medical condition. The responsibility to obtain professional medical assistance and to initiate any follow-up medical care to confirm results of screenings or tests is mine alone, and not that of the Pharmacy or its affiliates. No other person will have access to my personal medical profile and/or test results without my express verbal or written permission. Aggregate data may be used for statistical and research purposes. I voluntarily consent to receive the Services under the terms described in this Agreement.
Release
I voluntarily assume all risks of physical or other problems that may result from the Pharmacy’s Services and I release the Pharmacy, its affiliates and their employees and owners (the “Pharmacy Group”) from all claims, damages, liabilities and expenses (including attorney’s fees and costs) of any kind, including injury or death, arising from or related to the Services provided by the Pharmacy (the “Claims”), known or unknown, that I, or anyone claiming on my behalf, might now or later have as a result of the negligence of any member of the Pharmacy Group and I agree not to sue or otherwise assert any Claims against any member of the Pharmacy Group.
I am at least 18 years of age, or if I am under age 18, I understand that I may not receive Services from the Pharmacy unless my parent or guardian signs this Agreement. I HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND ALL MY QUESTIONS WERE ANSWERED TO MY SATISFACTION BEFORE SIGNING THIS AGREEMENT.
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PARENT OR GUARDIAN SIGN BELOW, IF APPLICABLE
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PERSONAL HISTORY QUESTIONNAIRE
Our ability to draw effective conclusions about your present state of health and how to improve it depends, to a significant extent, on your ability to respond thoughtfully and accurately to both these written questions and those posed by the Consultant during your consultations. Health issues are usually influenced by many factors. Accurately assessing all the factors and comprehensively managing them is the best way to deal with these health challenges. Your careful consideration of each of the following questions will enhance our efficiency and will provide for more effective use of your scheduled consultation time. These questions will help to identify health and nutritional issues and will assist us in helping you to achieve your individual goals.
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Please Select Appropriate Boxes
Ongoing Problems
Please order current and ongoing problems by priority and fill in all fields as completely as possible:
(Include children, parents, relatives, and/or friends and the ages of each individual):
Past Illness, Injury and Surgical History
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INJURIES
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DIAGNOSTIC STUDIES
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OPERATIONS
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Hospitalizations
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How often have you have taken antibiotics?
How often have you taken oral steroids (e.g., Cortisone, Prednisone, etc.)?
What medications are you taking now?
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List all vitamins, minerals, and other nutritional supplements that you are taking. Please indicate the dosage and how many times per day each supplement is taken:
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Childhood
Diet
How much of the following do you consume each week?
Meals
Place a check mark next to the food/drink that applies to your current diet
Check All That Apply
Check All That Apply
Check All That Apply
Check All That Apply
Check All That Apply
Bowel Movements
Please select items below with information about your bowel movements:
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How well have things been going for you?
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Family History
- Father
- Mother
- Brothers/Sisters:
- Child:
- Child:
- Child:
- Child:
- Paternal relative:
- Maternal relative:
FOR WOMEN ONLY
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