Patient Intake Forms

Telehealth|Telemedicine

Symptoms - Step 1 of 6

	None	Mild	Moderate
General fatigue or lack of energy	NoneGeneral fatigue or lack of energy None	MildGeneral fatigue or lack of energy Mild	ModerateGeneral fatigue or lack of energy Moderate
Decreased physical strength	NoneDecreased physical strength None	MildDecreased physical strength Mild	ModerateDecreased physical strength Moderate
Decreased endurance	NoneDecreased endurance None	MildDecreased endurance Mild	ModerateDecreased endurance Moderate
Get winded going up a flight of stairs	NoneGet winded going up a flight of stairs None	MildGet winded going up a flight of stairs Mild	ModerateGet winded going up a flight of stairs Moderate
Difficulty recovering after exercise/labor	NoneDifficulty recovering after exercise/labor None	MildDifficulty recovering after exercise/labor Mild	ModerateDifficulty recovering after exercise/labor Moderate
Unexplained joint pain	NoneUnexplained joint pain None	MildUnexplained joint pain Mild	ModerateUnexplained joint pain Moderate
Unexplained muscle aches	NoneUnexplained muscle aches None	MildUnexplained muscle aches Mild	ModerateUnexplained muscle aches Moderate
Falling asleep shortly after dinner/lunch	NoneFalling asleep shortly after dinner/lunch None	MildFalling asleep shortly after dinner/lunch Mild	ModerateFalling asleep shortly after dinner/lunch Moderate
Night sweats or sudden hot flashes	NoneNight sweats or sudden hot flashes None	MildNight sweats or sudden hot flashes Mild	ModerateNight sweats or sudden hot flashes Moderate
Decrease in libido (sex drive)	NoneDecrease in libido (sex drive) None	MildDecrease in libido (sex drive) Mild	ModerateDecrease in libido (sex drive) Moderate
Weight gain	NoneWeight gain None	MildWeight gain Mild	ModerateWeight gain Moderate
Increased body fat (especially around the waist)	NoneIncreased body fat (especially around the waist) None	MildIncreased body fat (especially around the waist) Mild	ModerateIncreased body fat (especially around the waist) Moderate
Loss of muscle tone	NoneLoss of muscle tone None	MildLoss of muscle tone Mild	ModerateLoss of muscle tone Moderate
Loss of body hair	NoneLoss of body hair None	MildLoss of body hair Mild	ModerateLoss of body hair Moderate
More body hair	NoneMore body hair None	MildMore body hair Mild	ModerateMore body hair Moderate

	None	Mild	Moderate
"Brain fog" or difficulty concentrating	None"Brain fog" or difficulty concentrating None	Mild"Brain fog" or difficulty concentrating Mild	Moderate"Brain fog" or difficulty concentrating Moderate
Decrease in motivation	NoneDecrease in motivation None	MildDecrease in motivation Mild	ModerateDecrease in motivation Moderate
Feeling depressed, irritable, or "grumpy"	NoneFeeling depressed, irritable, or "grumpy" None	MildFeeling depressed, irritable, or "grumpy" Mild	ModerateFeeling depressed, irritable, or "grumpy" Moderate
Recent decline in work performance	NoneRecent decline in work performance None	MildRecent decline in work performance Mild	ModerateRecent decline in work performance Moderate
Memory issues or general forgetfulness	NoneMemory issues or general forgetfulness None	MildMemory issues or general forgetfulness Mild	ModerateMemory issues or general forgetfulness Moderate

	Yes	No
Hypertension	YesHypertension Yes	NoHypertension No
Heart Disease	YesHeart Disease Yes	NoHeart Disease No
Stroke	YesStroke Yes	NoStroke No
Autoimmune	YesAutoimmune Yes	NoAutoimmune No
Diabetes	YesDiabetes Yes	NoDiabetes No
High Cholesterol	YesHigh Cholesterol Yes	NoHigh Cholesterol No
Obesity	YesObesity Yes	NoObesity No
Cancer	YesCancer Yes	NoCancer No
COPD/Asthma	YesCOPD/Asthma Yes	NoCOPD/Asthma No
Prostate/BPH	YesProstate/BPH Yes	NoProstate/BPH No
Gastrointestinal	YesGastrointestinal Yes	NoGastrointestinal No
Hormone disorder	YesHormone disorder Yes	NoHormone disorder No
Allergic reaction	YesAllergic reaction Yes	NoAllergic reaction No
Do you regularly use tobacco?	YesDo you regularly use tobacco? Yes	NoDo you regularly use tobacco? No
Do you regularly consume alcohol?	YesDo you regularly consume alcohol? Yes	NoDo you regularly consume alcohol? No
Do you regularly use recreational drugs?	YesDo you regularly use recreational drugs? Yes	NoDo you regularly use recreational drugs? No

AGREEMENT, AUTHORIZATION, TERMS OF SERVICE, CONSENT WAIVER, & ACKNOWLEDGMENT

1. Informed Consent *

I have the capacity (and ability) to make decisions regarding my own health. The medical provider, clinic, or staff has disclosed information on the treatment, test, or procedure in question, including the expected benefits and risks, side effects, and the likelihood (or probability) that the benefits and risks will occur. I fully comprehend the relevant information that is being provided to me, and if I have any questions or concerns regarding my medications or treatments, I promise to ask the clinic. I understand that Superior Genetix is prescribing medications / treatments, for one or more of the following conditions(s): Hormone replacement, weight loss, erectile dysfunction, health and wellness, anti-aging, vitamin deficiency or other. When I take these treatments, I may experience certain reactions or side effects. In addition to performing my own research on the medication I am receiving. I have performed (or will have performed) blood work, a medical health questionnaire, a discussion with my primary care provider, a consultation with a Superior Genetix staff member, and a final appointment with a Superior Genetix Prescribing Physician. I have requested information, discussed, and researched literature on the medication I will be using and I am familiar with the benefits, potential risks, and dosing protocols. I understand that my medications will be delivered to my home or the clinic, from the pharmacy, with labels outlining dosage and a package insert that explains potential risks, and side effects. I agree to read these thoroughly. I agree that if I do not receive a list of potential risks and side effects with my prescription, I will contact Superior Genetix Health & Wellness Inc. staff IMMEDIATELY. I understand I should not smoke tobacco or consume alcohol regularly while using certain medications. I also acknowledge that I should exercise, maintain a healthy diet, and follow up with my primary care provider on a regular basis. I understand that HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use and the liability is on the patient not the doctor. I have discussed the reason for taking these medications with my primary care provider, pharmacist, prescriber, or other licensed health practitioner. I understand why Superior Genetix is prescribing them, and the risks associated with taking certain medications including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke or heart attack. I understand that there are different risks for different medications. I have discussed these risks and the reasons for taking them, with my doctor. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT. I understand that there is no guarantee that these measures will be effective at preventing the negative side effects mentioned above, or others that we do not yet know about. I am aware that it is my responsibility to report any adverse effects to my primary care physician and Super Genetix Health & Wellness, Inc. IMMEDIATELY. I accept the possible risks of hormone therapy and other related treatments, and wish to have my provider prescribe them for me. It is important to be sure that you have information about the risks and benefits of hormone replacement therapy, peptides, and other medications before you take any treatment. The physician has your informed consent for treatment through telehealth remote examination.

2. Waiver & Release of Liability *

I release from liability and waive my right to sue Superior Genetix Health & Wellness,Inc, their employees, officers, volunteers, subcontractors, Physicians, Practitioners, Prescribers, subcontractors, and all agents (collectively “Superior Genetix”) from any and all claims, including claims of negligence, resulting in any injury, illness, death, or economic loss I may suffer or which may result from treatment. I am voluntarily participating in treatment. I understand that there are potential risks and side effects that may be associated with my participation in this treatment. I assume all risks of my participation in treatment, whether known or unknown to me.I agree to hold Superior Genetix harmless from any and all claims, loss or damage ,liabilities and costs, including attorney’s fees, as a result of my participation in treatment. I have read this document, and I am signing it freely. I understand the legal consequences of signing this document, including (a) releasing Superior Genetix from all liability, (b) waiving my right to sue Superior Genetix, (c) and assuming all risks of participating in any medical treatment provided or offered by Superior Genetix. I acknowledge that Superior Genetix may recommend products or services to me that may improve treatment outcomes, and that the clinic may or may not receive third party remuneration from these affiliated companies.

3. Patient & Clinic Relationship *

I agree and acknowledge that I have provided an honest and thorough medical and health history to Superior Genetix Health & Wellness, Inc. (collectively “the clinic”). The clinic will order labs and review my bloodwork results as needed. I agree to notify Superior Genetix if I am prescribed any new medication from another physician. I agree that I will have a physical examination performed by either the clinic or my primary care physician prior to beginning new treatments. I have consulted with my primary care physician regarding the risks and benefits of hormone replacement therapy, peptides, or weight loss medications. I came to Superior Genetix Health & Wellness, Inc. with a medical complaint, and I understand the connection existing between my medical complaint, my medical history, the physical examination and the treatment I am being prescribed. I fully understand that it is my responsibility to have routine physical examinations performed by my primary care physician to ensure that I have no disease(s) which might make any Superior Genetix treatment inappropriate for my condition. I have consulted with my primary care physician, pharmacist, or other health professional and hereby warrant that I do not have any conditions, and I am not taking any medications that would make hormone replacement therapy,peptide, or weight loss treatments contraindicated. I agree that all telehealth, telemedicine, on-line, video medical consultations and treatments, will be deemed to have occurred in the state where the physician is physically located and licensed to practice medicine, which may be in another state from my own. I have been provided contact information for Superior Genetix staff, and I understand that I have the opportunity to contact them at anytime. I agree that a satisfactory and valid patient/doctor/clinic relationship exists. I agree that Superior Genetix does not "co-treat" patients for testosterone replacement therapy, and they are not permitted to share patient information directly to anyone other than "the patient".

4. Authorization For Delivery of Medications *

I hereby authorize Superior Genetix staff to act on my behalf to accept medication delivery from an FDA licensed compounding pharmacy, or the clinic’s dispensing physician, and deliver my medication and refills to me as prescribed by my physician. I understand that medications can be picked up at the clinic or mailed to my provided address as often as ordered/prescribed by the physician. This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

5. No Guarantee of Services *

We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up/intake process, complete the health questionnaire, provide the appropriate blood work, completed a consultation, and conclude a physician’s examination. At the physician’s discretion only, you will be provided medications and/or services during your program at Superior Genetix.

6. Refund Policy *

I understand that there can be no refunds or returns on prescribed medications, blood work, appointments, or consultations. Superior Genetix and all of its coinciding locations reserve the right to have a NO RETURN and NO REFUND policy.

7. Insurance Claims *

I understand that Superior Genetix does not accept insurance, Medicare, or Medicaid. I agree that if I use insurance for any lab-work or treatments, that Superior Genetix is not responsible for any portion insurance may not cover.

8. Price Transparency, Fees, and Costs *

There are NO membership fees and no hidden costs. The patient is responsible for the cost of prescribed treatment, and blood work. The price of medication and lab work includes all administrative costs. Patients are NOT obligated to order blood work with the clinic if they have access to a lower cost. Any third party lab work must meet the compliance of the prescribing physician.

Today's date *

Name *

First

Middle

Last

Please sign here *

Clear Signature

By signing, I acknowledge that I have read and understand all the terms outlined in lines 1-8 above

🔒 Promise of Health & Medical Confidentiality

Patient Agreement and Understanding of Privacy

We recognize and respect the absolute importance of your privacy and the confidentiality of your personal health information (PHI). This document confirms our commitment to protecting your information.

What We Will Protect:

All records and information pertaining to your care, including but not limited to:

Medical history, diagnoses, and treatment plans.
Laboratory results and imaging reports.
Billing and payment information.
Personal identifying information (name, address, date of birth).

Our Promise:

Your PHI will be kept strictly confidential and will not be disclosed to any third party without your explicit written authorization, except in the following limited circumstances:

Treatment: Sharing information with other healthcare professionals directly involved in your care.
Payment: Disclosing information necessary for billing and collecting payment for services rendered.
Healthcare Operations: Using information for internal management, quality improvement, and administrative tasks.
Legal Requirements: When disclosure is mandated by law (e.g., reporting certain communicable diseases, valid court order).

We are legally and ethically bound to maintain the security and privacy of your records. By signing below, you acknowledge that you have been informed of our privacy practices.

Notice of Non-Disclosure to Third Parties *

Superior Genetix maintains a strict policy of non-disclosure regarding the release of patient information to external entities (e.g., employers, insurance providers, or government agencies). I "the Patient", understand that it is my sole responsibility to obtain my medical records from the clinic and facilitate the transfer of information to any third party. By signing below, I agree to manage all external documentation requirements personally and waive the right to request direct clinical transmission to third parties.

Today's date *

Your name *

First

Middle

Last

Please sign here *

Clear Signature

By signing, I acknowledges that they have read and understand: Agreement, Authorization, TOS, Waiver, Acknowledgment, Hipaa, Confidentiality, Privacy, and Non-Disclosure to Third Parties. I authorize Superior Genetix to contact me via email or text message regarding health-related information. This includes, but is not limited to, appointment reminders, clinical requests, and other necessary treatment-related correspondence.

Patient Intake Forms

Telehealth|Telemedicine

Telehealth Patient Intake Form

Let's Begin With Your Symptom Assessment

Tell Us About Your Health History & Medical Background.

AGREEMENT, AUTHORIZATION, TERMS OF SERVICE, CONSENT WAIVER, & ACKNOWLEDGMENT

🔒 Promise of Health & Medical Confidentiality

📸 Please Take A Picture Of Your ID

Clicking below submits your clinical file and moves you to our secure checkout to expedite your final steps before getting prescribed: