PCR COVID-19 TESTING INTAKE FORM

Please read these terms carefully and agree to the terms below.

Ivermectin has a 30 year history of safe use in humans and the side effect profile appears mild for the most part. However, the past use of ivermectin does not predict the safety and side effects seen when used for COVID-19 because we are using much higher doses when treating and preventing COVID-19. For scabies and parasite infections the usual dose is one time 0.2mg/kg. For COVID-19 prevention the dose is 0.2mg/kg twice a week indefinitely. For acute treatment, the recommended dose is 0.4mg/kg daily until symptoms resolve and it may be continued for 7-14 days total. These doses are MUCH higher than any used in the past. Based on my experience they are still safe and in thousands of patients I have seen no lasting or serious reactions to high-dose ivermectin use, but my data is imperfect and there may have been serious or severe side effects.

Also when used on a new disease, side effects could be different than those recorded in the past. For example, the most severe side effects of ivermectin in the past were only seen in the setting of treatment for a certain parasitic disease. The other relatively common side effect that has been seen in the past is elevated liver function tests which could indicate liver damage, reported in 2% of patients. While on ivermectin you should get liver function tests done on a monthly basis. There are also a number of other more severe side effects seen less than 1% of the time. All that being said, Tylenol and Advil use has been shown to increase the risk of heart failure and death and those are available over the counter. All medications do carry some risk that you should be aware of and in our judgment the risk is acceptable, given the disease.

Alcohol can increase the blood levels of ivermectin, so should be avoided when taking ivermectin. Using alcohol with Ivermectin may increase the risk of side effects. These are the common side effects reported with ivermectin in general:

Cardiovascular: Tachycardia (4%), peripheral edema (3%), facial edema (1%), orthostatic hypotension (1%)

Central nervous system: Dizziness (3%)

Gastrointestinal: Diarrhea (2%), nausea (2%)

Not to be used in pregnancy, or by those who might become pregnant- sexually active women should use contraception.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:

I acknowledge that off-label prevention and treatment for COVID-19 and related illnesses, like presumed post-viral syndrome due to COVID-19 AKA long COVID or long haul syndrome, has become a highly charged and political issue and poses numerous personal and professional risks to practitioners who prescribe these alternative, unapproved treatments, that, though presumed and believed to be safe and effective based on the best available evidence, may in fact be harmful and could cause severe disability and even death, which can in fact occur with any and all medical treatments in some percentage of patients, but physicians involved in these negative outcomes are shielded from liability when their peers agree their treatments were warranted. This is not the case with prevention and treatment of COVID-19 and related illnesses like long COVID. Where prescribing practitioners are acting outside the bounds of medical establishment consensus, therefore in order to obtain treatment that is not physician peer, FDA, NIH or CDC approved, but may nevertheless be beneficial, I agree to release Dr. Angela Straface and all her associates from all medical liability and malpractice claims related to any and all care, including but not limited to preventive, acute and chronic treatments for COVID-19 and presumed and/or diagnosed post-viral syndrome due to COVID-19, AKA long COVID or long haul syndrome.

YOU MUST AGREE TO THE TERMS MENTIONED ABOVE IN ORDER TO CONTINUE.

I agree to the above release from medical liability and malpractice claims.

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I have read through all the above information and if I have questions I will ask the doctor.

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I certify that I have been informed of the risks and benefits of off-label treatment for COVID-19.

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I consent to being evaluated via telemedicine and being treated with off-label medications that have NOT been FDA approved, are NOT on the NIH treatment guidelines, and are NOT recommended by any US governmental authority.

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I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects.

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Medical Disclaimer

NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.

Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at Feel Ideal 360.

Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out our medical questionnaire. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge and agree that Dr. Straface is providing a COVID-19 PCR test on myself and I am paying for a test with the physician. The outcome will be based solely on the physician's medical testing supplies/equipment provided by the medical vendor and the fee is non-refundable.

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I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Straface to proceed with our telemedicine visit.

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PCR COVID-19 TESTING INTAKE FORM

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