Fill and Sign the Patient Release Form

Patient Waiver and Release Agreement Regarding Being Prescribed Adipex 1. I, ______________________ (Name of Patient) consent to taking the drug Adipex pursuant to a prescription for Dr. _______________ (Name of Physician) . _______________________ (Name of Physician) has informed me of the reasons he deems the taking of this drug to be advisable and has advised me of the risks and possible complications of taking this drug which include the following possible side effects:  blurred vision,  dizziness,  dry mouth,  sleeplessness,  irritability, and  stomach upset and constipation. 2. I hereby promise that if these or any other side effects persist or become bothersome, I will immediately inform ___________________ (Name of Physician) . I also promise to immediately inform _____________________ (Name of Physician) if I experience chest pain, nervousness, a pounding heart, urination difficulty, mood swings/changes, breathing difficulties, or swelling. If I feel dizzy or lightheaded, I will avoid driving or engaging in activities requiring alertness. If I notice other side effects not listed above, I will immediately contact ____________________ (Name of Physician) . 3. ____________________ (Name of Physician) has advised me of the availability, risks, advantages and disadvantages of alternative drug and physical therapy. 4. I have had all of my questions fully answered to my satisfaction with respect to the use of this drug. I understand that there are no guarantees as to the results of taking this drug. 5. I do hereby unconditionally and expressly waive all claims and defenses that might be brought or asserted by me in any court or administrative action against _____________________ (Name of Physician) for prescribing this drug to me. I agree that this Agreement is voluntary and that it is binding on me or any individual or entity claiming by or through me or on my behalf. 6. I further agree to pay all attorneys fees and costs incurred by _______________________ (Name of Physician) in the event I, or anyone on my behalf, bring any action or claim against ____________________ (Name of Physician) in violation of any term, condition or provision of this Agreement. 7. The invalidity of any portion of this Agreement will not and shall not be deemed to affect the validity of any other provision. If any provision of this Agreement is held to be invalid, the parties agree that the remaining provisions shall be deemed to be in full force and effect as if they had been executed by both parties subsequent to the expungement of the invalid provision. 8. The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 9. This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ______________. 10. Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 11. This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 12. Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. WITNESS my signature this the _________________ (date) . _________________________ (Printed Name of Patient) _________________________ (Signature of Patient) This Waiver and Release instrument was, on the day and year shown above, signed by __________________ ( Name of Patient) in our presence. ________________________ ________________________ (Printed Name of Witness) (Printed Name of Witness) ________________________ ________________________ (Signature of Witness) (Signature of Witness)