Please enable JavaScript in your browser to complete this form. - Step 1 of 7Were you referred to us ? *YesNoIf you answered yes, please tell us who referred youNextWhat type of treatment(s) are you interested in ? *Testosterone replacement therapyHGH or Anti-AgingWeight lossSexual enhancementPeptide therapyOther hormone replacement therapy optionsVitamins and supplementsNextSuperior Genetix, Inc. New Patient IntakePlease complete the form below Name *FirstMiddleLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of birth *Driver's license number **This is required for all prescriptionsPhone *Ethnicity *American Indian or Alaskan NativeHispanic or Latino AsianWhiteBlack or African AmericanNative HawaiianPatient DeclinesOtherPhysician or primary care provider *Please provide us the name & phone number of your primary doctor or other health care provider.Marital status *MarriedSingleDivorcedWidowedSex *MaleFemaleTransgenderNon-binaryGender neutralMedical History *HypertensionHeart diseaseStrokeAutoimmuneDiabetesHigh cholesterolObesityCancerCOPD/AsthmaProstate/BPHGastrointestinalHormone disorderAllergic reactionNone of the aboveAllergies *If you do not have any known allergies, please put "NONE" Current medications *If you are not currently on any medications, please put "NONE".Do you currently/regularly use the following (check all/any that apply) *TobaccoAlcoholRecreational drugsNoneAre there any serious health concerns or other issues you feel the Physician should be aware of ? *If you are not aware of any underlying health issues, please put "NONE".NextInformed Consent for Hormone Replacement TherapyBecause 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 have read and agree to the Informed Consent statement *I accept the possible risks of hormone therapy and other related treatments, and wish to have my provider prescribe them for me.Name *FirstMiddleLastToday's date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please sign here *Clear SignatureNextGeneral Terms, Policies, and Patient Authorization for Delivery of MedicationsI 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. Please check the box below *I have read, and I understand the General Terms, Policies, and Patient Authorization for Delivery of Medications. Please sign here *Clear SignatureNextHIPPA Acknowledgement and Consent*Patient acknowledgement of receipt of notice of privacy practices, consent/limited authorization, and release form. Name *FirstMiddleLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Please list any other parties who can access to your health information.*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. If you do not prefer to share your health information with anyone, please check the box belowNANameFirstLastRelationshipPhoneNameFirstLastRelationshipPhoneI authorize contact from Superior Genetix, Inc to convey specific health related information via: *Cell phoneHome phoneWork phoneEmailTextIf unable to reach me: *Leave a detailed messageLeave a general message to return the callDo NOT leave a messageI authorize Superior Genetix, Inc to notify me by email and text to confirm my appointments, treatment plans, lab results, refill reminders, and billing.YesAcknowledgment & Consent *I agree to the HIPPA Patient Acknowledgement Form. I acknowledge and authorize that Superior Genetix, Inc. 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, Inc, under the current HIPPA Omnibus Rule, provides you this information with your knowledge and consent.Name *FirstMiddleLastToday's date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please sign here *Clear SignatureNextFee Acknowledgement & AgreementAll 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* 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)Referral code: Name *FirstMiddleLast*Please enter the exact name indicated on the card.Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAuthorization *By checking this box and signing this form, you give Superior Genetix, 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. Email *Please sign here *Clear SignatureBy signing, you agree to the terms of this fee agreement and acknowledge that you intend on proceeding with treatment.Welcome to the Superior Genetix 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 Submit