Please complete the forms below and click the submit button. Once sent, these forms and medical information will be evaluated by Salud Integral medical staff. Dosing Instructions of Administration will be provided upon approval.

Medical History Background

Treatments Received or currently receiving

Global Quality of Life Scale

(Please check only one of them)

Pain scale

On a scale of 0 to 10, 0 being no pain, and 10 being the worst pain you have ever had in your life, at what level is your pain at this moment?

Using the same scale, what has been your average pain level in the:

Please list all the medications you are currently taking

Condition of Participation Agreement for ANVIRZEL@ Treatment

Salud Integral, S. A. de C. V. ("Salud Integral") is collecting ongoing clinical data for the use of the drug ANVIRZEL®, approved by the Health Secretary of Honduras, Sanitary Register Number HN-PN-1020-0010. The clinical data collected is designed to gain additional information about the pharmacokinetics and pharmacodynamics of ANVIRZEL®, as well as to evaluate the impact of ANVIRZEL® upon the quality of life in patients with diseases or conditions. The accuracy of the clinical data is dependent upon well-controlled and closely monitored conditions. Acceptance for receipt of ANVIRZEL® is conditioned upon full compliance with the terms of this agreement. I understand that my failure to comply with the Condition of Participation could be detrimental to the assessment of the integrity and quality of the clinical data gained through my participation. I further understand that my participation in the clinical research with Salud Integral is subject to my compliance with the Condition of Participation and that any failure to comply may result in my rejection from any further receipt of ANVIRZEL®. Therefore, I agree to cooperate fully and comply with all of the Conditions of Participation set out herein below.

Authorization for Release of Medical Records

RECIPIENT: Salud Integral 

I, or my authorized representative, authorize the release any medical information in my records including patient file, medical charts, x-rays, evaluations, notes, laboratory results and other tests results and documentation related to my care to the named recipient above for the purposes of medical evaluation. This consent to release information is good until receipt of a written revocation of the authorization by me or my authorized representative. A facsimile or copy of this authorization shall be deemed the same as an original.

Consent to Assume Risks

I am requesting permission for myself to receive ANVIRZEL® 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: ANVIRZEL® is a new drug approved for sale by the Secretary of Health of Honduras, C.A. ANVIRZEL® 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 ANVIRZEL® may be of unknown benefit; and the use of ANVIRZEL® may create unknown risks.

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

I understand that there may be unanticipated side effects or symptoms as a result of using ANIVIRZEL®, 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 ANIVIRZEL® 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 ANVIRZEL® 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 ANVIRZEL®:

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 ANVIRZEL® and assume full responsibility as a result of giving my consent.