ipharmacy

Relative	Condition	Living?	If deceased, at what age?
Mother		Yes No
Father		Yes No
Sibling		Yes No
Other		Yes No

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 submission of this update form 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 update of your medical conditions and medical history at iPharmacy.com

By saving and submitting this form, you consent willingly to iPharmacy.com's and its parent company's use and disclosure of your protected healthcare information for submitting to your designated doctor and for submitting to pharmaceutical companies and/or their employees, or their agents and their employees, for considering your candidacy for a clinical trial. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

I hereby authorize iPhamarcy.com to generate a form for me to submit to my doctor for the purpose of "Ask My Doctor is this drug is right for me".

I hereby authorize iPharmacy.com to submit my sign-up to pharmaceutical companies (or their employees or their agents and employees) to consider me as a candidate for a clinical trial of a new drug.

Description	Doctor	Location	Year

Ask My Doctor If This Drug is Right For Me

Medical Conditions*

ALLERGIES

List your allergies and describe the reactions to your body:

MEDICATION

List the medications you are currently taking including the dosage:

FAMILY HEALTH HISTORY

List any major conditions/illnesses that your immediate family members have had:

SURGICAL HISTORY

List any surgeries, fractures, major illnesses, or hospitalizations that you have had:

MEDICAL HISTORY

Have you ever had any of the following?

HEALTH CONCERNS

SOCIAL HISTORY

Complete the following if applicable:

HIPAA Compliance Patient Consent Form