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Superior Genetix Health & Wellness, Inc. | New Patient Health & Medical Forms

Please complete the form below

Name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Date of birth *

Please upload an image of a valid state issued Photo I.D.

Click or drag a file to this area to upload.

*Proper identification is required by law for all prescription medications and lab work.

Your Primary Care Physician *

Please provide us the name & phone number of your primary doctor or other health care provider.

Marital status *

Married
Single
Divorced
Widowed

Sex *

Male
Female

Medical and Health History *

I want to improve my health and I feel I can benefit from hormone replacement therapy, peptides, or weight loss medications..

Hypertension *

Heart Disease *

Stroke *

Autoimmune *

Diabetes *

High cholesterol *

Obesity *

Cancer *

COPD/Asthma *

Prostate/BPH *

Gastrointestinal *

Hormone disorder *

Allergic reaction *

Current Medications *

If you are not currently on any medications, please put "NONE".

Allergies *

If you do not have any known allergies, please put "NONE"

Are there any serious health concerns or other issues the Physician should be aware of ? *

If you are not aware of any underlying health issues, please put "NONE".

What was your last known blood pressure reading ? *

Do you currently/regularly use the following (check all/any that apply) *

Tobacco
Alcohol
Recreational drugs
None

Tell us about the current symptoms you are experiencing that brought you to us today (ex. fatigue, weight gain, no libido) *

*This will help us evaluate you for the treatments you are interested in.

Today's Date *

I swear that the information I provided is true and accurate to the best of my knowledge *

Signature

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

1. Informed Consent *

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. 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) a discussion with ym primary care provider, a consultation with a Superior Genetix staff member, and a final appointment with a Superior Genetix Physician. I have requested and received 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 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 that I may be required toI 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.sign and date an additional informed consent at any time. 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. When hormone levels are brought back to “normal” for your age there is much evidence that your overall health will improve.HRT is the most effective treatment for hormone deficiencies. 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. I accept the possible risks of hormone therapy and other related treatments, and wish to have my provider prescribe them for me.

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.

3. Patient & Clinic Acknowledgement *

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 from LabCorp as needed. 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.

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 if I use insurance for any lab-work or treatments that Superior Genetix is not responsible for any portion insurance may not cover.

Today's date *

Name *

First

Middle

Last

I acknowledge that I have read and understand all the terms outlined in lines 1-7 above. *

I agree

Please sign here *

HIPPA & PRIVACY

HIPPA Acknowledgement, Medical Release, Privacy Rule, and Consent *

*Patient acknowledgement of receipt of notice of privacy practices, consent/limited authorization, and release form.

Your name *

First

Middle

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Who are we authorized to share your information with ? *

(Ex. Spouse, Children, or put NONE

If unable to reach me: *

Leave a detailed message
Leave a general message to return the call
Do NOT leave a message

I authorize Superior Genetix to notify me by email and text to confirm my appointments, treatment plans, lab results, refill reminders, and billing. *

Acknowledgment & Consent *

I agree to the HIPPA Patient Acknowledgement Form. I acknowledge and authorize that Superior Genetix may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. Superior Genetix, under the current HIPPA Omnibus Rule, provides you this information with your knowledge and consent.

Today's date *

Please sign here *

Fee Acknowledgement & Agreement

All new patients are required to pay a one-time fee that covers: Client enrollment, blood work, lab & chart examination, and the consultation with the Prescriber/Pracitioner/Physician *

$300 - I have not had blood work done recently and I need to get my blood work done.
$150 - I have my blood work and I will upload a copy of those results below

* You will receive an invoice by email for this transaction. Treatment is guaranteed, or there is no fee.

Upload your blood work

Click or drag a file to this area to upload.

(If applicable) Please provide us a copy of your most recent blood work (must be less than 90 days old)

Authorization *

By checking this box and signing this form, you give Superior Genetix Health & Wellness, Inc. permission to send all treatment and refill related invoices to the email you provided below. You also understand that there can be no refunds or returns on prescribed medications, blood work, or medical prescriber consultations.

Please sign here *

By signing, you agree to the terms of this fee agreement and acknowledge that you intend on proceeding with treatment.

Welcome to the Superior Genetix Health & Wellness Family !

Congratulations on beginning your journey to better health and wellness.

Once you click submit, you will receive a confirmation email from our client intake manager "Gina". She will arrange your blood work (if needed) and your tele-consultation with the Prescriber/Practitioner/Physician.

If you have any questions regarding your intake, please call us Monday-Friday between the hours of 12 noon-3pm at (727) 275-0611

You can also email the intake manager directly at SuperiorGenetix@protonmail.com