MEBENDAZOLE/IVERMECTIN

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Your privacy is very important. The following information is only used to assess your health goals and determine what treatments are appropriate and to avoid any possible reactions.

After filling out the form, one of our pharmacy staff will reach out to you to discuss your request for this treatment. If you have not heard from us in 48 hours after submitting the form, please call 1-423-975-0597.

Patient 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: *

ex. 01/05/1960

Weight (required)

Oncologist

Are you in need of a provider?

YesNo

What is the best way to contact you?*

Phone callEmailTextAll

Are you allergic to anything?*

NOYES

If yes, please list allergies:

Are you looking for active treatment or propylaxis?

YesNoUnsure. I would like more information.

Type of Cancer and Stage:

Treatments previously tried:

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 grant permission

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.

I grant permission.

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?

YESNO

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

YESNO

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:

YESNO

Signature

Date

Mebendazole / Ivermectin Assessment

Disclosures & HIPAA Consent Form