2.  I hereby state that I am an adult age 18 or older, I am aware of any possible side effects of Chantix, and I hereby agree to answer truthfully all of the questions on my questionnaire.

3.  I understand that no doctor can guarantee that Chantix, even if prescribed, will provide the results I seek. I acknowledge that no guarantees have been made to me as to the results as there is no known medical treatment that gives 100% satisfaction to everyone, nor are there any guarantees against unfavorable results, risks or complications.  Chantix is NOT a magic pill.  It is a STOP-SMOKING aid by medically lessening cravings for cigarettes and alleviating symptoms of physiological withdrawal   - YOU HAVE TO BE MOTIVATED TO STOP SMOKING!

4.  I understand that although no serious adverse reactions have been reported to date, I may suffer adverse effects from Chantix.    The most common side effects in about 30% of users is nausea which goes away in the initial days of treatment.  Other common side effects include but not limited to: abdominal pain, flatulence, vomiting, constipation, dry mouth, changes in taste perception, insomnia, changes in dreaming, nightmares, headache, fatigue, lethargy, skin problems, rashes.  Rare side effects include but not limited to:  respiratory, cardiac disorders, blood and lymphatic disorders.

5.  I understand that although in general there are no serious adverse reactions on rare occasions one may develop allergic reactions or rare unreported sids. I understand that Chantix is a newly approved medication by the FDA and although extensively tested there may be risks and possibilities of complications that may occur in patients even when the utmost care, judgment and skills are used.  I acknowledge that there are no guarantees made to me as to favorable or unfavorable results.  I accept and fully understand the risks known and unknown and accept the risk of substantial and serious harm and or complication even to the loss of bodily functions and/or life itself from using Chantix.

6.  I further acknowledge that if I am prescribed Chantix by Medical Wellness Center, I have full knowledge that no physician, nurse or medical personnel can predict as whether I would or would not have any adverse effects since every individual has a unique biological/chemical make-up. I understand that all possible risks and/or complications do not need to be explained to me, nor do I consider this practical or even possible because risks and complications may occur that have never been recorded before. I hereby release Medical Wellness Center and any associated physicians from any and all liability whatsoever with any adverse effects I may suffer from my use of Chantix.

7.  I am participating in this Medical Wellness Center Online Chantix  Consultation at my own choice, at my own expense and my own liability and assume all responsibility for my use of Chantix. I acknowledge and agree that I initiated this contact with Medical Wellness Center, and I agree that all on-line medical consultations and treatments will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine which may be in another state from my own.

8.  I fully understand that it is my responsibility to have routine physical examination to ensure that I have no disease(s) which might make Chantix  inappropriate for my condition. I further agree that I have consulted with my physician and/or pharmacist and hereby warrant that I do not have any conditions or I am not taking any medications that would make Chantix contraindicated. I further agree to immediately notify any doctor whose present care I am under that I have chosen to take Chantix.

9.  I further understand that not answering truthfully to any of the medical consultation questions or falsifying information in order to obtain prescription medication is a violation of both State and Federal U.S. law. I hereby agree to answer all questions on medical consultation truthfully.

10.  I understand that if I have failed in any way to provide Medical Wellness Center with my complete and accurate medical history or if I fail to notify Medical Wellness Center of any changes in the future, then I can not hold Medical Wellness Center or its physicians responsible for any adverse effects I may suffer and I am solely responsible for any adverse effects I may suffer from taking or continuing to take Chantix or from participating in this program.

11. If after review of my consultation questionnaire, a physician determines that Chantix  is appropriate treatment, I hereby authorize a charge of $49.95 + $9.55 shipping and processing fees to be charged to my credit card for this physician consultation. If not approved there is no charge to the credit card.  I also understand that if my medical consultation is approved by a Medical Wellness Center physician, there is absolutely NO credit given or cancellations accepted for any reason even if another physician renders a different opinion and recommends not to use the medication.  Therefore before submitting consultation request, I must check with any other treating physicians in regards to treatment.  If after submitting my consultation I later change my mind and choose not to fill the written prescription I receive or not to use the medication or to discontinue use of the medication for any reason there are NO refunds.    Once submitting the consultation, unless email notification is sent immediately within 5 minutes of submitting the consultation (email button is on consultation page immediately below the submit button), there is absolutely NO cancellations or NO refunds given for any circumstance.

12. I hereby waive a physical exam at this time and agree to continue to have routine medical examinations by my regular physicians.

13. Also, I agree that if approved the medication will be used only by the person for whom prescribed, and I will not give medication or prescription to another party. I also understand the contraindications and warnings regarding Chantix and pregnant or potentially pregnant woman or breast feeding women should not take Chantix.

14.  I have read the contraindications which include:

• Kidney disease, renal impairment, kidney transplant  or any other medical disorder of kidney function
• Woman who are pregnant, potentially pregnant or breast feeding. 
• Contraindicated in anyone under 18 years of age. 
• Chantix treatment is contraindicated in anyone who is on INSULIN, ASTHMA MEDICATIONS, or COUMADIN OR WARFARIN (Blood thinner). 

15. I understand that Medial Wellness Center is unable to accept any requests for cancellations or refunds for any reason once submitted.  There are no refunds given even if one changes one's mind for any reason, has a change in one's medical condition or upon the advice of another physician no longer desires the drug.  One does not have to fill the prescription or take the medication, but there are NO refunds for the online consultation service.