Fillable Hepatitis C Treatment Agreement (Sunshine Health)

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Hepatitis C Treatment Agreement (Sunshine Health)

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The Hepatitis C Treatment Agreement (Sunshine Health) form is 1 page long and contains:

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  • 8 check-boxes
  • 4 other fields

Country of origin: US
File type: PDF

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__________________________________________ ___________________
__________________________________________
1301 International Parkway Suite 400 Sunrise, FL 33323 866-796-0530 TDD/TTY 800-955-8770
Hepatitis C Treatment Agreement
I, ________________________________________ talked to my doctor and agree:
I will not use alcohol or drugs, and
I have been drug and alcohol free for over one month, and
I know how to avoid being re-infected with Hepatitis C, and
I will use two forms of birth control during treatment and for six months after
treatment (applies to both males and females) and,
I agree to have a monthly pregnancy test as ordered by my doctor and,
I will tell my doctor if I become pregnant (females only) and,
I agree to complete the entire course of treatment and,
I will have all lab tests as ordered by my doctor.
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Hepatitis C Treatment Agreement (Sunshine Health)

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Completed 31 January 2021

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