Agreement and Liability Waiver for Free 3-Month OTC Birth Control Sponsored by Allure Alliance

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Allure Alliance Inc. is proud to sponsor 3-6 months of free over-the-counter (OTC) birth control for individuals in the Austin Metro Area. Before we proceed, please complete this liability waiver and acknowledgment form. This ensures that you understand the terms of this program and accept all associated risks.

By completing this form, you acknowledge that Allure Alliance Inc. is not a licensed medical provider, and you accept full responsibility for using the provided OTC birth control at your own risk. You are legally allowed to refuse to offer your geographical information, and doing so will not result in any consequences to you.

Email *

How many months of OTC birth control do you need.

3 months

6 months

Recipient Information

Full Name

Email Address

Shipping Address

(Please provide the address where you would like the birth control shipped.)

Please read each statement carefully and check the box to confirm your acknowledgment: I Agree *

I understand that Allure Alliance Inc. is not a medical provider and does not provide medical advice or care.

I assume all risks associated with using the OTC birth control, including potential side effects or adverse reactions.

I understand that Allure Alliance Inc. has not conducted any evaluation of my health or suitability for this product.

I accept full responsibility for consulting a licensed healthcare provider as needed before or during use.

I release Allure Alliance Inc. from any liability, claims, or damages related to my use of the provided product.

I agree to use the product according to the manufacturer’s instructions.

Required

zipcode

(type decline if you choose to opt out of this question)

How old are you? *

Which term best describes you? *

What term best describes you- choose all the apply *

African American/Black

Latinx

Native American

White

Asian/ Pasific Islander

Other:

Required

Which of the following best describes your relationship status? *

What term best describes you?

Female

Male

Trans-woman

Trans-man

Gender non-conforming (GTC)

I am interested in FREE Plan B. *

Yes

Please confirm the following by checking the box below:

I have read and understood the terms of this agreement and liability waiver. I voluntarily accept all associated risks and release Allure Alliance Inc. from any liability. *

Yes

Electronic Signature:
By typing your name below, you acknowledge that this serves as your electronic signature and confirmation of agreement. *

YYYY

Send me a copy of my responses.

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