Consultation

REQUIRED "HOW TO" VIDEOS(Required)

I have watched the videos and know how to give myself an IM & SUB-Q injection

www.citizenmeds.com/howtoinject (2 VIDEOS AVAILABLE HERE)

PROPER USE: Pills/Injections(Required)

[Injections]: I understand these injections are to be self injected in the frontal thigh area, as portrayed in the video (WWW.CITIZENMEDS.COM/HOWTOINJECT). I agree I will use the syringes and vitamins as directed. [Pills]: I understand that my prescription medications are only to be used by me. My pills at Citizen Meds will have an expiration date that will be on my bottle. Injectables: Once the vials are opened, are to be discarded 30 days after opening. I understand , after the 30 day period, injectable vials are considered expired and should be discarded by me.

Injection Consent(Required)

CONSENT FORM: I acknowledge that I have received instructions and educational material from Citizen Meds for the administration of home injections. I acknowledge that the risks of injections has been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. - I understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction. - I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - I understand that it is my responsibility to maintain follow up appointments with my physician at Citizen Meds as needed. By signing this form, I assume full responsibility for receiving my injections and release Citizen Meds and its physicians from any liability or responsibility for any reactions, conditions, self-injection procedures or injuries in conjunction with the injection therapies.

Pills and Medication Consent(Required)

CONSENT FORM: I agree to properly use my medications responsibly as indicated on the instructions I receive on my prescription vial. I acknowledge that I understand and have received instructions and educational material from Citizen Meds for my medications. I acknowledge that the risks have been discussed with me. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - I understand that it is my responsibility to maintain follow up appointments with my physician at Citizen Meds as needed. By signing this form, I assume full responsibility for receiving my medication and release Citizen Meds and its physicians from any liability or responsibility.

I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT www.citizenmeds.com/refund-policy/ - I authorize CITIZEN MEDS to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.(Required)

I AGREE

I agree to give my consent to treat. I have read the Telehealth Consent located at https://citizenmeds.com/telehealth-consent/(Required)

I AGREE

I agree to CITIZEN MEDS Terms and Conditions. I have read the Terms and conditions located at https://www.citizenmeds.com/terms-and-conditions/(Required)

I AGREE

PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)(Required)

Signature: By signing below, I hereby acknowledge that the above statements are true and correct to the best of my knowledge.(Required)

Date SIGNED (mm/dd/yyyy):(Required)

ONE-TIME OR SUBSCRIPTION ORDER?(Required)

ONE-TIME ORDER ONLY
RECURRING SUBSCRIPTION 20% OFF (Start getting 20% off when this rebills every month. Automatically applied at rebilling)

You can choose to make this order a one-time order or plan to get it delivered every month on a recurring subscription. ALL recurring subscription orders receive 20% off. (If you are choosing to have recurring orders of Semaglutide or Tirzepatide, you are agreeing to a titrated dosing schedule and charges for higher doses) Monthly subscription will be billed and shipped EVERY 25 DAYS. Cancel anytime at least 48 hours before next billing cycle by emailing [email protected]

***IMPORTANT*** YOU ARE AGREEING TO A SUBSCRIPTION PROGRAM

I AGREE TO A MONTHLY SHIPMENT AND AUTOMATIC BILLING TO MY CREDIT CARD EVERY 25 DAYS AFTER THIS PURCHASE

(IF YOU DO NOT WANT THIS OPTION, CLICK "ONE TIME ORDER' IN THE PREVIOUS QUESTION)

Step 1 of 8 - Goals