Ivermectin/HCQ for Covid Rx Request (CardConnect Iframe)

Name *

First Name Last Name

Birth Date *

Date

Gender *

Male Female

Pregnant *

Yes No

Weight (lbs) *

Address *

Street Address

Street Address Line 2

City State

Zip Code

Cell Phone *

Please enter a valid phone number.

Email *

example@example.com

Drug Allergies *

Medical History *

Current Medications *

Are you currently taking the medicine called Coumadin/Warfarin? *

Yes No

Currently hospitalized? *

Yes No

Tested Positive for Covid? *

Yes No

History of smoking/vaping? *

Yes No

Any symptoms? *

Yes No

Fever? *

Yes No

Respiratory symptoms? *

Yes No

Other Symptoms (if any) *

Additional info (optional)

Reason for reaching out to us (optional)

FLCCC Ivermectin Protocol of Interest (Select at least 1) *

Early Outpatient Post Exposure Prevention Long Haul "Just in Case" Hydroxychloroquine (HCQ) Unsure

PLEASE BE ADVISED THAT YOU ARE USING IVERMECTIN AND HYDROXYCHLOROQUINE AT YOUR OWN RISK. THE PHARMACIES, FHL MEDICAL CORP AND ITS EMPLOYEES, AND AFFILIATES ARE NOT RESPONSIBLE FOR ANY SIDE EFFECTS, REACTIONS, ADVERSE EVENTS, ETC. ASSOCIATED WITH THE USE OF IVERMECTIN OR HYDROXYCHLOROQUINE. IF YOU DO EXPERIENCE ANY UNWELCOME SIDE EFFECTS, PLEASE CONTACT US IMMEDIATELY. BY CHECKING THE BOX BELOW, YOU HAVE READ AND AGREE TO THE TERMS AND CONDITIONS AND UNDERSTAND THE RISKS ASSOCIATED WITH IVERMECTIN AND HYDROXYCHLOROQUINE.

By checking the box below, I agree that I will not hold FHL Medical Corp legally or medically responsible for an adverse reaction should the patient choose to take Ivermectin, HYDROXYCHLOROQUINE, or anything prescribed by FHL Medical Corp. I agree to not hold FHL Medical Corp medically neglectful, pursue any form of malpractice, nor any criminal and civil suits.

As a potential patient, I acknowledge and understand that Ivermectin and HYDROXYCHLOROQUINE has been deemed ‘Highly Not Recommended’ by the WHO, FDA, CDC, and NIH. Should I choose to not disclose a proper medical history, the clinician cannot be held liable nor can any medical license in any state be reviewed or held accountable.

By checking the box below, I consent to the creation of a healthcare provider-patient relationship with Faith Hope Love Medical Corp, and to receive telemedicine services from their medical providers.

Terms and Conditions Agreement *

I understand and agree to the terms and conditions listed above

2-Name *

First Name Last Name

2-Birth Date *

Date

2-Gender *

Male Female

2-Pregnant *

Yes No

2-Weight (lbs) *

2-Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

2-Cell Phone *

Please enter a valid phone number.

2-Email *

example@example.com

2-Drug Allergies *

2-Medical History *

2-Current Medications *

2-Are you currently taking the medicine called Coumadin/Warfarin? *

Yes No

2-Currently hospitalized? *

Yes No

2-Tested Positive for Covid? *

Yes No

2-History of smoking/vaping? *

Yes No

2-Any symptoms? *

Yes No

2-Fever? *

Yes No

2-Respiratory symptoms? *

Yes No

2-Other Symptoms (if any) *

2-Additional info (optional)

2-Reason for reaching out to us (optional)

2-FLCCC Ivermectin Protocol of Interest (Select at least 1) *

Early Outpatient Post Exposure Prevention Long Haul "Just in Case" Hydroxychloroquine (HCQ) Unsure

PLEASE BE ADVISED THAT YOU ARE USING IVERMECTIN AND HYDROXYCHLOROQUINE AT YOUR OWN RISK. THE PHARMACIES, FHL MEDICAL CORP AND ITS EMPLOYEES, AND AFFILIATES ARE NOT RESPONSIBLE FOR ANY SIDE EFFECTS, REACTIONS, ADVERSE EVENTS, ETC. ASSOCIATED WITH THE USE OF IVERMECTIN OR HYDROXYCHLOROQUINE. IF YOU DO EXPERIENCE ANY UNWELCOME SIDE EFFECTS, PLEASE CONTACT US IMMEDIATELY. BY CHECKING THE BOX BELOW, YOU HAVE READ AND AGREE TO THE TERMS AND CONDITIONS AND UNDERSTAND THE RISKS ASSOCIATED WITH IVERMECTIN AND HYDROXYCHLOROQUINE.

By checking the box below, I agree that I will not hold FHL Medical Corp legally or medically responsible for an adverse reaction should the patient choose to take Ivermectin, HYDROXYCHLOROQUINE, or anything prescribed by FHL Medical Corp. I agree to not hold FHL Medical Corp medically neglectful, pursue any form of malpractice, nor any criminal and civil suits.

As a potential patient, I acknowledge and understand that Ivermectin and HYDROXYCHLOROQUINE has been deemed ‘Highly Not Recommended’ by the WHO, FDA, CDC, and NIH. Should I choose to not disclose a proper medical history, the clinician cannot be held liable nor can any medical license in any state be reviewed or held accountable.

By checking the box below, I consent to the creation of a healthcare provider-patient relationship with Faith Hope Love Medical Corp, and to receive telemedicine services from their medical providers.

2-Terms and Conditions Agreement *

I understand and agree to the terms and conditions listed above

3-Name *

First Name Last Name

3-Birth Date *

Date

3-Gender *

Male Female

3-Pregnant *

Yes No

3-Weight (lbs) *

3-Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

3-Cell Phone *

Please enter a valid phone number.

3-Email *

example@example.com

3-Drug Allergies *

3-Medical History *

3-Current Medications *

3-Are you currently taking the medicine called Coumadin/Warfarin? *

Yes No

3-Currently hospitalized? *

Yes No

3-Tested Positive for Covid? *

Yes No

3-History of smoking/vaping? *

Yes No

3-Any symptoms? *

Yes No

3-Fever? *

Yes No

3-Respiratory symptoms? *

Yes No

3-Other Symptoms (if any) *

3-Additional info (optional)

3-Reason for reaching out to us (optional)

3-FLCCC Ivermectin Protocol of Interest (Select at least 1) *

Early Outpatient Post Exposure Prevention Long Haul "Just in Case" Hydroxychloroquine (HCQ) Unsure

PLEASE BE ADVISED THAT YOU ARE USING IVERMECTIN AND HYDROXYCHLOROQUINE AT YOUR OWN RISK. THE PHARMACIES, FHL MEDICAL CORP AND ITS EMPLOYEES, AND AFFILIATES ARE NOT RESPONSIBLE FOR ANY SIDE EFFECTS, REACTIONS, ADVERSE EVENTS, ETC. ASSOCIATED WITH THE USE OF IVERMECTIN OR HYDROXYCHLOROQUINE. IF YOU DO EXPERIENCE ANY UNWELCOME SIDE EFFECTS, PLEASE CONTACT US IMMEDIATELY. BY CHECKING THE BOX BELOW, YOU HAVE READ AND AGREE TO THE TERMS AND CONDITIONS AND UNDERSTAND THE RISKS ASSOCIATED WITH IVERMECTIN AND HYDROXYCHLOROQUINE.

By checking the box below, I agree that I will not hold FHL Medical Corp legally or medically responsible for an adverse reaction should the patient choose to take Ivermectin, HYDROXYCHLOROQUINE, or anything prescribed by FHL Medical Corp. I agree to not hold FHL Medical Corp medically neglectful, pursue any form of malpractice, nor any criminal and civil suits.

As a potential patient, I acknowledge and understand that Ivermectin and HYDROXYCHLOROQUINE has been deemed ‘Highly Not Recommended’ by the WHO, FDA, CDC, and NIH. Should I choose to not disclose a proper medical history, the clinician cannot be held liable nor can any medical license in any state be reviewed or held accountable.

By checking the box below, I consent to the creation of a healthcare provider-patient relationship with Faith Hope Love Medical Corp, and to receive telemedicine services from their medical providers.

3-Terms and Conditions Agreement *

I understand and agree to the terms and conditions listed above

4-Name *

First Name Last Name

4-Birth Date *

Date

4-Gender *

Male Female

4-Pregnant *

Yes No

4-Weight (lbs) *

4-Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

4-Cell Phone *

Please enter a valid phone number.

4-Email *

example@example.com

4-Drug Allergies *

4-Medical History *

4-Current Medications *

4-Are you currently taking the medicine called Coumadin/Warfarin? *

Yes No

4-Currently hospitalized? *

Yes No

4-Tested Positive for Covid? *

Yes No

4-History of smoking/vaping? *

Yes No

4-Any symptoms? *

Yes No

4-Fever? *

Yes No

4-Respiratory symptoms? *

Yes No

4-Other Symptoms (if any) *

4-Additional info (optional)

4-Reason for reaching out to us (optional)

4-FLCCC Ivermectin Protocol of Interest (Select at least 1) *

Early Outpatient Post Exposure Prevention Long Haul "Just in Case" Hydroxychloroquine (HCQ) Unsure

PLEASE BE ADVISED THAT YOU ARE USING IVERMECTIN AND HYDROXYCHLOROQUINE AT YOUR OWN RISK. THE PHARMACIES, FHL MEDICAL CORP AND ITS EMPLOYEES, AND AFFILIATES ARE NOT RESPONSIBLE FOR ANY SIDE EFFECTS, REACTIONS, ADVERSE EVENTS, ETC. ASSOCIATED WITH THE USE OF IVERMECTIN OR HYDROXYCHLOROQUINE. IF YOU DO EXPERIENCE ANY UNWELCOME SIDE EFFECTS, PLEASE CONTACT US IMMEDIATELY. BY CHECKING THE BOX BELOW, YOU HAVE READ AND AGREE TO THE TERMS AND CONDITIONS AND UNDERSTAND THE RISKS ASSOCIATED WITH IVERMECTIN AND HYDROXYCHLOROQUINE.

By checking the box below, I agree that I will not hold FHL Medical Corp legally or medically responsible for an adverse reaction should the patient choose to take Ivermectin, HYDROXYCHLOROQUINE, or anything prescribed by FHL Medical Corp. I agree to not hold FHL Medical Corp medically neglectful, pursue any form of malpractice, nor any criminal and civil suits.

As a potential patient, I acknowledge and understand that Ivermectin and HYDROXYCHLOROQUINE has been deemed ‘Highly Not Recommended’ by the WHO, FDA, CDC, and NIH. Should I choose to not disclose a proper medical history, the clinician cannot be held liable nor can any medical license in any state be reviewed or held accountable.

By checking the box below, I consent to the creation of a healthcare provider-patient relationship with Faith Hope Love Medical Corp, and to receive telemedicine services from their medical providers.

4-Terms and Conditions Agreement *

I understand and agree to the terms and conditions listed above

Ivermectin/HCQ for Covid Rx Request

Patient

Patient 2

Patient 3

Patient 4