I hereby release www.vaniqa-cream.com  and all of their employees and contractors including physicians from all liability associated with my Vaniqa® consultation and/or the use of Vaniqa®.  I understand that no physician, nurse or administrative personnel can guarantee that Vaniqa®, even if prescribed, will provide the results I seek. I hereby agree to answer truthfully all of the medical questions during my consultation.  I also understand that if I fail in anyway to furnish www.vaniqa-cream.com with my complete and accurate medical history or become aware of any changes in the future which I have not notified www.vaniqa-cream.com of then I cannot hold them responsible for any adverse effects I may suffer.

I am fully aware that it is my responsibility to have an annual physical exam, including any suggested laboratory test, to ensure that I have no disease, which might make Vaniqa® inappropriate for me.  I also understand that this consultation is not a substitute for my need to visit a local physician for my annual exam. I further agree to notify all physicians, whose present care I am currently under or any physician who I will engage in the future, of my decision to use Vaniqa® so they may advise to continue or discontinue the use of medication.

 I understand a qualified licensed physician, who may or may not be licensed to practice medicine in my state, will evaluate the information I am providing.

If approved, I irrevocably appoint www.vaniqa-cream.com  to be my agent and have my prescription and any refills filled by the Pharmacy of its choice and acknowledge that the prescription obtained for me is non-transferable. We are unable to accept returns or issue refunds for any orders due to the fact that this is a prescription medication.

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