Microsoft word - mass dispensing program consent form
ABERDEEN MASS DISPENSING PROGRAM HOUSEHOLD ACKNOWLEDGEMENT AND CONSENT FORM (Print name-in ink) __________________________________________________________ (Print address) ____________________________________, Boynton Beach, Florida, 33472 AS HEAD OF HOUSEHOLD,IUNDERSTAND, ACKNOWLEDGEANDCONSENT TOTHEFOLLOWING STIPULATIONS: 1. CARPOOL RESIDENT MEDICATION PICK-UP AUTHORIZATION FORM To permit my Representative togo to the clubhousetopick upmedications and instructions for myself, my family and my visiting guests, who are named on my Client Registration Form. 2. WORSENING MEDICAL CONDITION ADVICE INSTRUCTIONS To acknowledge that I will assist any household memberlisted on my Client Registration Form who has a Worsening Medical Condition over the last 48 hours in seeking Medical Attention as soon as possible. 3. PREGNANT & BREAST FEEDING WOMEN INSTRUCTIONS To acknowledge that if any of the above individuals are listed on my Client Registration Form, I wil instruct them or their guardian to consult with their personal physicians for additional instructions on how to take the antibiotics- Cipro, doxycycline or amoxicillin. 4. Samples of the specific strain of pathogen to which we may have been exposed wil have to be tested to determine if it is susceptible (sensitive) to Amoxicillin (penicillin). It is unlikely that any confirmation will be available during the early stages of our Antibiotic Dispensing Program. But this information will be most useful should it be necessary to provide treatment for a total of 60 days. According to the dispensing guidelines from the Palm Beach County Health Department, all children under 8 years of age will be dispensed Cipro, according to their weight. Should a child under 8 be allergic to Cipro, then doxycycline wil be dispensed according to the child’s weight. Cipro will also be the recommended drug of choice for Pregnant or Breast feeding women. If allergic to Cipro, then doxycycline will be dispensed due to life threating illnesses, such as Anthrax. A potential side effect of Cipro is that it may cause joint pain. Everyone is advised to report any joint pain to their physician while taking Cipro. A potential long-term side effect of doxycycline is the staining of, but not damage to, tooth enamel. Typically, the staining only becomes visible after prolonged use of doxycycline (months). In either case, the advice of the child’s physician should be sought to determine which medication to use for your Child(ren), and yourself. It is best that this information be obtained prior to an emergency and during a routine doctor’s visit. Since we are dealing with a possible life threating disease, doxycycline and Cipro are the best available medications to use . 5. To release and discharge the Aberdeen Property Owners Association, Inc., the Aberdeen Golf & Country Club Inc., all members and participants in the Aberdeen Mass Dispensing Program, including but not limited to the Coordinator of the Program, the Medical Supervisor, carpool Representatives, the Aberdeen Mass Dispensing Program Team, Volunteer Members and all volunteers partaking in the administration of said program from any and all liability for any civil damages as a result of any act or omission of said persons and/or Groups unless such damages result from any act or omission under circumstances demonstrating a willful, wanton reckless disregard for the consequences, so as to affect the life or health of another. 6. To Acknowledge that I have been given a printed Anthrax Treatment Information sheet to be shared by my household. Head of Household Signature_________________________________________________________ Date_________ IMPORTANT- DISTRIBUTE TWO COPIES PER HOUSEHOLD: YOU MUST SUBMIT ONE SIGNED COPY AT THE DISPENSING SITE AT THE TIME OF A REAL EVENT. ONE COPY SHOULD BE RETAINED BY HEAD OF HOUSEHOLD FOR YOUR RECORDS. IF YOU CHOOSE TO OPT OUT OF THIS PROGRAM, THAT IS, REFUSE THE MEDICATION OFFERED, Then: PLEASE SIGN HERE _____________________________DATE_____ TO RELEASE AND DISCHARGE THE ABERDEEN PROPERTY ASSOCIATION INC., AND THE ABERDEEN GOLF AND COUNTRY CLUB from any damage or loss that I may sustain as a result of opting out and the election to opt out is strictly voluntary on my part and not as a result of coercion or payment of any kind.
Q. DOES EFAMOL® EPO CAUSE ANY SIDE EFFECTS? A. Clinical studies using Efamol® EPO, in a wide range of diseases have included monitoring for potential side effects. Outside the context of clinical trials, well over 1,000,000 Kg of EPO have been taken since the mid 1970's. This wide consumer use has provided ample opportunity to collect reliable information about any side effects that may
Ratificado mediante Ley 1743 (1-Junio-2005) Los Estados Miembros de la Organización de los Estados Americanos, Convencidos de que la corrupción socava la legitimidad de las instituciones públicas, atenta contra la sociedad, el orden moral y la justicia, así como contra el desarrollo integral de los pueblos; Considerando que la democracia representativa, condición indispensable para la estab