Prescription Medication Consent Form

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  • Prescription Medication Consent Form

    First Name

    Last Name

    Phone Number

    Date of Birth

    Email

    Your Address

    State

    Zip Code

    City

    Current Medication

    Are you taking any current medication?

    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:

    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, Ciprofloxacin.

    If Yes

    explain your allergies

    Are you PREGNANT or LACTATING?

    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


    All medication is a self-pay purchase. Insurance is not accepted. Only CVS or Walgreens
    Pharmacy Depending on your state price may vary.

    • Azithromycin between $20 - 30

    • Doxycycline between $30 - 60

    • Cefixime between $20 - 30

    • Acyclovir between $40 - 50

    • Metronidazole between $10 - 20