WAIVER OF LIABILITY
I hereby release Westech and all of their employees and contractors including physicians from all liability associated with my XenicalВ® consultation and/or the use of XenicalВ®. I understand that no physician, nurse or administrative personnel can guarantee that XenicalВ®, 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 Westech with my complete and accurate medical history or become aware of any changes in the future which I have not notified Westech of than I cannot hold them responsible for any adverse effects I may suffer.
I realize obesity is associated with the following health conditions, cardiovascular disease, strokes, diabetes, gallbladder disease, certain types of cancer, gout (joint pain caused by excess uric acid), osteoarthritis (deterioration of the joints), sleep apnea (interrupted breathing during sleep) etc. XenicalВ® may assist you with weight reduction but it does not treat these possible associated conditions.
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 XenicalВ® 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 XenicalВ® so they may advise to continue or discontinue use of the medication.
I understand XenicalВ® is indicated for obesity management including weight reduction and weight management when used in conjunction with a reduced caloric diet. The diet should be nutritionally balanced and contain approximately 30% of the calories from fat. I understand secondary to Xenical’sВ® mechanism of action there is a decrease in the absorption of the fat soluble vitamins A, D, E, K and beta carotene, therefore physicians recommend a daily supplemental multivitamin.
I understand the side effects of XenicalВ® include but are not limited to, gas with discharge, fatty or oily stools, an increase in the frequency of bowel movements and bowel incontinence. (These side effects are generally mild and resolve early in treatment) For more information regarding XenicalВ® please visit Roche Pharmaceuticals @ “
I understand XenicalВ® can be taken in conjunction with a mildly reduced choleric diet up to 3 times per day, the standard dose is 120 mg. Finally, I understand a qualified and licensed physician who may or may not be licensed to practice in my state will evaluate the information I am providing.
If approved, I irrevocably appoint Westech to be my agent and have my prescription and any refills filled by the Pharmacy of its choice and acknowledge that the Rx obtained for me is non-transferable. We are unable to accept returns or issue refunds for any order due to the fact that this is a prescription medication.