Rejuvenation Vial Intake

REQUIRED "HOW TO" VIDEO *

I have watched the video and know how to give myself an injection. I will use the injection instruction video provided by Clear Choice Pharmacy when it is made available to me.

I WILL FOLLOW THE INSTRUCTIONS AND DOSAGE AMOUNTS ON MY BOTTLE. I understand these injections are to be self-injected in the area written on my bottle. I will watch the video to learn how to self-inject. I will follow injection instructions provided by Clear Choice Pharmacy. I agree I will use the syringes and medication as directed.

I understand that my custom package is ordered for me. My vial or package will have an expiration date that is 28 days after opening. I understand that after the 28-day period, medications are considered expired and should be discarded by me.

I understand that my medication is prepared in a compounding pharmacy in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider.

CONSENT FORM

I acknowledge that I have received instructions and educational material from Clear Choice Pharmacy for the administration of home injections. I acknowledge that the risks of injections have been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc.

• If I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction.
• I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must verify that the date of this medication is current. If not, I will call for a renewal of my medication.
• I understand that it is my responsibility to maintain follow-up appointments with my physician as needed.

By signing this form, I assume full responsibility for receiving my injections and release Clear Choice Pharmacy and its physicians from any liability or responsibility for any reactions, conditions, self-injection procedures or injuries in conjunction with the injection therapies. I also understand that I am able to use Clear Choice Pharmacy services and go to any pharmacy of my choosing.

NO RETURNS

I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT https://clearchoicepharmacy.com/refund-policy. I authorize Clear Choice Pharmacy to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

I agree to give my consent to treat. I have read the Telehealth Consent located at https://clearchoicepharmacy.com/telehealth-consent.

I agree to Clear Choice Pharmacy's Terms and Conditions. I have read the Terms and Conditions located at https://clearchoicepharmacy.com/terms-and-conditions.

I understand my health information will be handled in accordance with HIPAA regulations. I have read the Privacy Policy located at https://clearchoicepharmacy.com/privacy.