COVID

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***DISCLAIMER: At present, the FDA has not approved use of Ivermectin for COVID-19 treatment or prophylaxis. Medication side effects, drug interactions, contraindications, and laboratory monitoring requirements should also be considered when dispensing these medications for treatment of COVID-19. There is a potential for toxicity with these medications.***

***If symptoms worsen or you have difficulty breathing, please seek medical attention.***

Full Name

First Last

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail

We will never SPAM or sell email addresses to third parties.

Phone:

ex. 555-555-5555

Birthdate: (You must be over 18)

ex. 01/05/1960

Weight (required)

Primary Care Provider

What is the best way to contact you?

Have you ever had a hypersensitivity to Ivermectin?

Are you allergic to anything?

If yes, please list allergies:

Have you had any of these health conditions in the past or present?

Do you follow a regular exercise program?

Do you smoke or chew tobacco products everyday?

Do you drink alcohol?

If yes, how much and how often?

What is your current level of stress?

List any oral MEDICATIONS you take daily:

List all oral VITAMINS or HERBS you take daily:

Female Clients

Are you pregnant or trying to become pregnant?

COVID Status

Date of COVID test?

Date

Date/time of known exposure?

Date

Hour MinutesAM/PM Option

Symptoms?

***If you checked ‘Chest pain or pressure’, please rank below with (1) being mildly uncomfortable, and (5) being significant/frightening/painful loss of breath.

NOTES or Additional Information

Attachments

I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation from treatments received. I am aware that it is my responsibility to inform the pharmacist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release ProCompounding Pharmacy and/or the prescriber from liability and assume full responsibility thereof. I grant permission for a pharmacist, employed by ProCompounding Pharmacy to collaborate with my primary care provider, or other collaborating prescriber to provide my treatment. This may include sharing medical information that is protected under HIPAA.

I give permission for a pharmacist, employed by ProCompounding Pharmacy, to collaborate with my primary care provider, or another collaborating prescriber to provide treatment. This may include sharing medical information that is protected under HIPAA.

Date

MonthDayYear

Signature

HIPAA COMPLIANCE PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that, by your signature, you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By granting consent of this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The pharmacy reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information, but the pharmacy does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The pharmacy may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm prescriptions?

May we leave a message on your answering machine at home or on your cell phone?

The following individuals have a right to access and discuss my patient information (this includes picking up prescriptions, requesting refills, and inquiring additional information about prescriptions):

Regarding the HIPAA COMPLIANCE PATIENT CONSENT FORM, I grant consent:

Signature

Date

Ivermectin Assessment

Disclosures & HIPAA Consent Form