Please enable JavaScript in your browser to complete this form.

First time patient AdelfaRx

To order AdelfaRx please complete the form below and click the submit button.

Pricing: 1 AdelfaRx box (60 tablets) is $220 plus shipping.

A secure online invoice will be sent to you after you submit the form. You will be able to pay using a major credit card once you have received this email.

Is your shipping address different from your home address?

MEDICAL OVERVIEW

Please provide a Written Commentary update: (Patient overview of current medical condition, results, and any questions you may have.)

Please list all the medications and treatments you are currently taking:

Are you currently taking any digitalic heart medication such as digoxin or any medications that fall into this category?

AdelfaRx has not received U.S.F.D.A. approval to treat, cure or prevent any specific illness.

Consent to Assume Risks

I am requesting permission for myself to receive AdelfaRx during the time period determined by my physician and in doing so I assume full responsibility for any and all risks of this action related to my current medical condition.

I have been informed by my physician as follows:  AdelfaRx is a new drug approved for sale by the Secretary of Health of Honduras, C.A. AdelfaRx has not received U.S.F.D.A. approval to treat, cure or prevent any specific illness.

     Because clinical data collection is ongoing:

The use of AdelfaRx may be of unknown benefit; and the use of AdelfaRx may create unknown risks.

I understand that I am voluntarily requesting the use of AdelfaRx and that my physician may not be knowledgeable of all the risks, if any, in the use of AdelfaRx. I acknowledge that there may be limited scientific information available about AdelfaRx.

I understand that there may be unanticipated side effects or symptoms as a result of using AdelfaRx, and that it is my responsibility to let the physician and other healthcare providers know if any unanticipated side effects or symptoms occur. If such side effects or symptoms occur, I understand that my physician may advise or direct administration of AdelfaRx be stopped. I understand that no guarantee or assurance has been made to me as to the results that may be obtained from the use of AdelfaRx or any side effects that may occur.

I hereby assume full responsibility for any or all risks of this action, and hereby release the following entities or individuals from any liability other than that stated herein and for any consequences that may result by my action in voluntarily consenting to the use and the receipt of AdelfaRx:

Salud Integral, S.A. de C. V.; Droguería Salud Integral, S. de R. L.; Phoenix Biotechnology, Inc.; Chisos, Ltd.; Laboratorios Y Distribuciones Francelia, S.A de C. V. , the referring physician and investigating physician.

However, nothing in this consent shall be construed to waive or appear to waive any of my legal rights, to release or appear to release the physician, the sponsor, or its agents from liability for negligence.

With full knowledge that there are unknown benefits and unknown risks, I consent to the use of AdelfaRx and assume full responsibility as a result of giving my consent.

PATIENT AFFIRMATION OF PERSONAL USE

I am voluntarily requesting AdelfaRx for personal use.

My medical evaluation for treatment began in Honduras and it is necessary that I continue to take AdelfaRx in the United States. I will continue under the care and supervision of my physician, and my physician is aware I am taking AdelfaRx.

I am receiving a supply of AdelfaRx in a clinical dose prescribed for my own personal use. The medication is self-administered, sublingually, and I have been instructed in this procedure.

Inclusion in a FDA Trial is not an option for me at this time and 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.

Patient afirmation of personal use