Prescription Medication Consent Form First Name Last Name Phone Number Date of Birth Email Your Address State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming Zip Code City Current Medication Are you taking any current medication? YesNo A59.09 - Trichomonas Infection B00.9 - Herpes Infection A74.9 - Chlamydia Infection A54.9 - Neisseria (gonorrea) Infection Please select the infection you need medication for: SelectA59.09B00.9A74.9A54.9 If Yes Let us know what the current medication are for. Are you allergic to any medication that you know off? Cefixim, Azithromizin, Doxzicline, Acyclovir Or ( Sildenafil viagra), Metronidazole YesNo If Yes explain your allergies Do you suffer from any medical conditions? If so, please list them. YesNo If Yes explain your medical conditions Are you PREGNANT or LACTATING? YesNo Pharmacy Name Pharmacy Phone Number 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. By Clicking on Submit you agree to all the declarations and policies of the company as has bene mentioned on the website, Sign here Medication Disclaimer: Important information, Please Read Medication Qualification To Qualify for Medication,please adhere to the following guidelines: Criteria Action Required Current infection tested by 247Labkit Qualifies for medication Requesting a refill Retest required for refill,if not, consult primary doctor for reneval not tested by 247Labkit Medication can not prescribed Pricing at CVS or Walgreens Pharmacies Medication Price Range Azithromycin $20-$30 Doxycycline $30-$60 Cefixime $20-$30 Acyclovir $40-$50 Metronidazole $10-$20
