Please complete the form below

Because of rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, it is important to be sure that you have information about the risks and benefits of hormone replacement therapy before you take the therapy we have discussed.

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. There may be other long-term beneficial effects of treatment.

The medical frame of mind is always evolving, so it is important to discuss safety, risks, and benefits with your doctor each year at your annual exam to find out what the latest information is.

Please read the following and sign:

I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them, and the risks associated with taking hormones 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 if I take any HRT medication. 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 hereby authorize Superior Genetix, Inc. 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 on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

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 process and physician’s examination.

At the physician’s discretion only, you will be provided medications and/or services during your program at Superior Genetix.

Insurance Claims and Usage

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

No Refund Policy

Superior Genetix, Inc. and all of its coinciding locations reserve the right to have a NO RETURN and NO REFUND policy.

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

*This could include your spouse, children, primary care physician, grandparents, or any caretakers who can have access to this patient’s records. You can click the “NA” box below if not applicable.