By signing this form, I acknowledge that I am voluntarily requesting that my pharmacist consult with me about my tobacco cessation options, and I understand the following:
- Pineville Pharmacy is not able to bill insurance for this consultation, the cost of this consultation is non-refundable, and I am fully responsible for the payment prior to the consultation.
- I will not seek any reimbursement from Pineville Pharmacy or its employees.
- The pharmacist is providing care based on the information that I provide. The pharmacist will explore Tobacco Cessation options, and how to use it.
- The pharmacist will try to answer all my questions about Tobacco Cessation, I understand that Pharmacist and Physicians have different educational training.
- If the Pharmacist is not able to provide my preference on tobacco cessation options, I will refer to my Primary Care Provider.
- Establishing a relationship with a Primary Care Provider is important in Tobacco Cessation therapy, if I do not currently have a relationship with a Primary Care Provider the pharmacist will attempt to establish one.
- Receiving prescription/therapy is not adequate replacement for annual check ups with my primary care provider.
- No form of tobacco cessation therapy is 100% effective, and the pharmacist is not liable if the methods/therapy provided does not work.
- I will contact my Pharmacist and Medical Health Provider with any changes regarding side effects, problems, or changes to my mental and physical health conditions.
- I give consent to my pharmacist and pharmacy staff members of Pineville Pharmacy to perform consultations at my own risk and authorize that Pineville Pharmacy and its staff members to possess a copy of my consultation forms.
- On behalf of myself, my heirs, and personal representatives, I indemnify the organizing body and all persons connected with Pineville Pharmacy from all outcomes that may result from my voluntary participation in the consultation.