I hereby confirm that the multidisciplinary entity known as ICB Clinics Pty Ltd ACN 664 060 646 herein referred to as the “ICB”, has fully explained to my absolute satisfaction all aspects negative and positive regarding my specific Peptide treatment. I hereby also confirm that I am completely satisfied with the opportunity that has been presented for me to have all of my related questions regarding but not limited to the treatment and alternative treatments answered. I have been specifically informed to the level that I completely understand and agree without compromise the following:
1. I solemnly swear that I have provided and told ICB everything to the best of my knowledge about my medical and or family medical history, if I experience an adverse effect due to me withholding information, intentional and or unintentional direct or indirect, aware or unaware, then I take full responsibility for my outcome and completely absolve ICB and its associates of all responsibility.
2. I have been told that I may experience an allergic reaction to the treatment which I understand is not likely but still can occur.
3. I understand that the complete treatment period for the Peptide will depend on my individual response to the treatment so time frames will vary any, and if any, type of positive result.
4. I understand it is critical I follow all of the before, during and after advice provided and explained to me by ICB.
5. I have been advised by ICB and its associates that the Peptide treatment I am potentially being prescribed at the discretion of ICB is a prohibited substance/s and treatment by the WADA (World Anti-Doping Agency) and the ASADA (Australian Sports Anti-Doping Authority). I have been advised that this is a prohibited substance/s and treatment for any professional athlete who competes, performs or plays in any type of sports whereby it is organised, monitored and or managed by a governing body or entity of any kind, anywhere in the world. I also unconditionally agree that prior to signing this agreement; it is my sole responsibility to know whether my activities fall within the categories of WADA and ASADA. Either way I absolve ICB and its associates such as prescribing doctors of all legal responsibility for my position as it is my sole responsibility.
6. I understand a further definition of a professional athlete/sports player can also be understood as someone who by playing a sport receives or has received monetary payment or other form of exchange for their performance by an associated entity of any description.
7. I hereby solemnly swear and confirm that I am not an elite athlete or professional performer as described in points (5) five and (6) six of this agreement. I do not engage in “any” professional activities and or any type of sports as described and neither do I intend to do so whilst under this or subsequent Peptide treatments for a revolving period of six (6) months. This six (6) month period recommences indefinitely every time I receive a new Peptide order of product. I am also aware that I am strictly not to engage in any type of elite or professional sports/competition/performance as described for a minimum period of (12) months after the last dose of this Peptide treatment or subsequent Peptide treatments which have been administered. This minimum (12) twelve month period recommences indefinitely every time I receive a new Peptide order of product.
8. If I consult any other physician concerning ICB treatment and or any other related symptom or condition, I will then hereby absolve ICB and its associates of any responsibility or duty of care regarding my results and or condition as I understand and completely agree that ICB is the only entity that provides me with the physician to which I will consult with for ICB treatments
9. I agree to have a follow up consultation with ICB every 30 days or as frequently requested by ICB medical team during any time whereby I am under ongoing ICB Peptide treatment.
10. I have been advised and agree that any further treatment or treatments that may arise as a consequence of any side effects, complications or dissatisfaction from this procedure will be my absolute financial responsibility. This includes but is not limited to procedures, products or any other requirement that may arise that necessitates a monetary payment.
11. I hereby unconditionally confirm and accept all clauses and inferences contained within this agreement extends in full capacity to any and all medical doctors working either for ICB, or are in a working agreement with ICB to prescribe my medical script and treatment. The medical doctors referred to in this clause are either providing me with my direct prescription or are a tertiary qualified medical doctor providing professional assistance to the prescribing medical doctor.
12. I confirm that I have been made aware of annexure one (1) which explains the potential side effects of my prescribed Peptide treatment. I have been informed that it is part of this agreement also referred to as page three. I understand annexure one explains to my complete satisfaction the potential side effects of undergoing my peptide treatment, therefore it is my educated decision to proceed. If for any reason I do not receive annexure one (1) I confirm it is my sole responsibility to ask for a copy of it in writing or otherwise it is understood that I am in agreement with everything stated in annexure one (1) and absolve ICB and its associates of any responsibility.
13. I understand that the Peptide treatment is a treatment and not a cure of any kind for any medical condition.
14. I hereby declare that I have been informed that this medication is not to be used while pregnant or lactating, therefore it is my responsibility to commence the administered protocols only once I have confirmed that I am not pregnant and I am under contraceptive medication which should be continued throughout the whole course.
