I, ______________________________, am being treated for a serious condition with the medication Anvirzel™. My medical evaluation for treatment began in Honduras and it is necessary that I receive treatment at Home. I will continue under the care and supervision of my physician and my physician is aware I am taking Anvirzel™ Therapy.

 

Physician's name	______________________________
Physician's address	______________________________
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Physician's phone	______________________________

          I am receiving a supply of Anvirzel™ in a clinical dose prescribed for my own personal use for the treatment of a serious condition from which I suffer. The medication is self administered and I have been instructed in this procedure.

          I am aware that a FDA Phase I trial for Anvirzel™ was conducted in the United States at the Cleveland Clinic in Cleveland, Ohio and that, according to the FDA Phase I Abstract, the Phase I trial concluded that the Anvirzel™ can be safely administered at doses up to 1.2 ml/m2/d (2.4 cc) without evidence of dose limiting toxicities. Participation in a trial is not an option for me at this time. Due to the seriousness of my medical condition, it is extremely important I follow treatment as prescribed.

          I declare that the above statements are true and correct to the best of my knowledge and belief.

 

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