Patient Pickup DECLARATION OF UNDERSTANDING AND RESPONSIBILITY FOR MEDICATION DISPENSEMENTPatient Name(Required) First Last Medication Name(Required)unitsmg(s)QuantityI hereby acknowledge the receipt and proper dispensation of the prescribed medication above from the Houston Medical Wellness Clinic. I confirm that I have inspected the provided medications and verified their accuracy according to my prescription. Furthermore, I affirm that I have received the quantity of injections listed above. The instructions concerning the appropriate administration of the medication have been comprehensively elucidated to me by the clinical staff. Consequently, I have a clear understanding of the same and do not harbor any lingering queries or concerns. I acknowledge the obligation to request clarification or additional information if needed at this point. I understand and accept that upon my personal inspection and subsequent possession of the medication, the responsibility for the maintenance and correct utilization of the medication solely rests on me. This includes ensuring proper storage conditions such as maintaining the correct temperature and safeguarding against any potential damage, especially during transit. Consequently, Houston Medical Wellness is hereby absolved from any liability concerning the integrity and efficacy of the medication once it has been officially dispensed and has exited the premises of the clinic. This declaration is made in good faith and signifies my understanding of the responsibilities and expectations associated with the possession and usage of the received medication. All my questions have been answered, and I do not have any further questions.Shots prepared byDate MM slash DD slash YYYY Legal Consent(Required) I agree to the terms and conditions.Consumer Disclosure Regarding Conducting Business Electronically, Signing Documents Electronically, and Receiving Electronic Notices and Disclosures Please read the information below, carefully, as it concerns your rights. eSignatures are an efficient way to execute an agreement with the same legal force and effect of a handwritten or “wet ink” signature. By signing this document you are agreeing that you have reviewed this Consumer Disclosure and consent and intend to transact business electronically; to use electronic signatures instead of wet ink signatures and paper documents, and to receive notices and disclosures electronically. You are not required to sign documents electronically or to receive notices and disclosures electronically. If you prefer not to transact business electronically, you may request paper copies from the “sending party” and withdraw your consent at any time, as described below. Scope of Consent By utilizing this Service, you agree to receive electronic signature documents with all related and identified documents, notices, and disclosures provided during your relationship with the “sending party.” You may withdraw your consent, at any time, by following the procedures outlined below. Paper Copies You are not required to sign documents electronically, or receive notices or disclosures electronically, and may request paper copies of documents or disclosures, if you prefer. You also have the ability to download and print any signed or unsigned documents sent to you through the electronic signature service. We may also email you a copy of all documents you sign using the electronic signature service. If you wish to receive paper copies instead of electronic documents you may close this web browser and request paper copies from the “sending party” by following the procedures outlined below. The “sending party” may apply a charge for additional expenses incurred by printing and mailing paper copies. Withdrawal of Consent You may withdraw your consent to receive electronic documents, notices or disclosures at any time. In order to withdraw consent you must notify the “sending party” that you wish to withdraw your consent to transact business electronically and to provide your future documents, notices, and disclosures in paper format. If at any time, after withdrawing your consent you choose to use our electronic signature system your use of this Service will, once again, evidence your consent to receive documents, notices, and disclosures, electronically. You may withdraw your consent to receive electronic notices and disclosures or execute an electronic signature by following the procedures described below. Withdrawing your consent, requesting a paper copy, or updating your contact information You always have the ability to download and print any documents sent to you through our electronic signature system. To withdraw your consent to conduct business electronically, sign documents electronically, and receive documents, notices, or disclosures electronically, please contact the “sending party” directly; by telephone, by email (sent to the “sending party” with any of the topics outlined below stated in the subject line of your email) or by postal mail to their mailing address specified to receive such notices. “Withdrawal of Consent To Transact Business Electronically” To allow the “sending party” to identify and facilitate your withdrawal of consent to transact business electronically, please provide your name, email address, the date on which you are withdrawing your consent, your telephone number and mailing address. “Requesting A Paper Copy” To allow the “sending party” to identify you to provide a paper copy of the document requiring your signature, the notice, or disclosure, please provide the sending party with your name, email address, mailing address, telephone number, and name of the document of which you are requesting a paper copy . “Update Your Contact Information” To allow the “sending party” to identify you in order to update your contact information, please provide them with your name, email address, mailing address, and telephone number. The “sending party” will inform you of any fees related to costs for printing and mailing paper copies or your withdrawal consent to transact business electronically. Signature(Required)CAPTCHA
