• Informed Consent: Erectile Dysfunction

  • Erectile Dysfunction Fact Sheet


    Consent for Services

    Before providing your consent, be sure that you understand both the pros and cons of receiving treatment from a pharmacy provider. If you have any questions, we will be happy to discuss them with you. Do not sign your name on this form until you have read and understood each statement and the pharmacist has answered any questions that you may have. This information is confidential.

    • I understand the benefits and risks of receiving treatment.
    • I have voluntarily chosen to receive care service by a pharmacy provider.
    • I understand that Pharmacists can assess and treat some authorized conditions, and administer certain services including diagnostic testing, and vaccinations.
    • I voluntarily assume full responsibility for any reactions or consequences that may result.
    • In the event of side effects, I understand I should call the pharmacy, my doctor, or 911.
    • I have had the opportunity to ask any questions I might have about the care and services provided to me by a pharmacy provider and the alternatives prior to my informed consent.
    • I give consent to receive care services by the pharmacy provider, including any medications recommended or prescribed, or instructions from the pharmacy provider.
    • I understand if the pharmacy provider cannot provide effective care, I may be referred to an appropriate care provider.
    • I have read or have had read to me all of the above statements and understand them.

    Authorization to Request Treatment

    I am requesting participation in receiving treatment for the pharmacist prescribed Erectile Dysfunction program. I certify that the information provided regarding eligibility for the treatment is accurate and request that the treatment be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so.

    I authorize the pharmacy providing services to release information to Medicare, Medicaid or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to the pharmacy providing services, I certify that the information provided about my Medicare, Medicaid or other coverage is correct.

    Acceptance of Financial Responsibility

    Notwithstanding anything previously set forth, I agree that I am responsible for and will promptly pay on demand any and all obligations to the pharmacy providing services including all self-pay balances as well as those charges for services not covered or disallowed by my insurance carrier.

    Disclosure of Records

    I understand that the pharmacy providing services may be required to or may voluntarily disclose my health information with respect to this treatment to my healthcare providers, my insurance plan, health systems and hospitals, and/or state or federal registries. I understand that the pharmacy providing services will use and disclose my health information as set forth in the pharmacy privacy policy (a copy is available by request from the pharmacy team).