I hereby release Murray Avenue Apothecary, Inc. and all of its affiliates (to include but not be limited to: all of its employees, owners, contractors, pharmacists and contracted employees) from any and all liability associated with or connected to my Biologically Identical Hormone Replacement Therapy (BHRT) or other compounded prescription therapies, consultation, recommendations, use of supplements and BHRT. I acknowledge that I am legally responsible for and aware of the potential side effects associated with BHRT. I understand that no doctor, nurse, pharmacist or administrative personnel can guarantee that BHRT will provide the results that I seek. I am participating in this program by my own choice, and assume all responsibility for my use of BHRT.
I fully understand that it is my responsibility to have an annual physical examination along with appropriate laboratory testing (at least yearly). I am currently under the medical supervision of a physician and I have consulted my physician about treatment options. I have been advised about the increased risks of heart disease, myocardial infarction, stroke, pulmonary emboli, thrombo-embolytic events, breast cancer, endometrial cancer, Alzheimer's and other dementias associated with the use of the synthetic hormones and, although there are no large multi center research studies linking the natural hormones with these negative outcomes, I release and hold harmless Murray Avenue Apothecary, Inc. and all of it's affiliates from any liability should I experience any reaction, complication or other problem (including permanent disability or death) caused by or alleged to be caused by, any treatment provided by or products dispensed by Murray Avenue Apothecary, Inc. or any of its affiliates.
In the event I must cancel my consultation, I will do so within 48 hours of the scheduled date, or I will be charged a no show/late cancellation fee of $50.00.
I have answered truthfully and completely all of the questions on this form.
