Get Started - Superior Genetix Health and Wellness

Let's Begin - Step 1 of 7

What is your email address ? *

Confirm Email

*This email will be used for important correspondence related to your treatment.

Were You Referred To Us? How Did You Hear About Us? *

Please identify who referred you. We would like to thank them.

Are you transferring to us from another clinic ? *

If you are coming from another clinic, please enter the name of that clinic below.

Your Symptoms

Tell us about what's bringing you in today.

Musculoskeletal & Body Composition

Loss of muscle mass/loss of muscle tone
Loss of strength/reduced muscle strength
Muscle weakness
Increased body fat (or weight gain/obesity)
Breast tissue development (gynecomastia or enlarged male breast tissue)
Osteoporosis (bone density loss)

Sexual & Urological

Reduced sex drive/low libido
Erectile dysfunction (including difficulty achieving/maintaining an erection, and poor quality/rare/absent morning erections)
Low semen/sperm volume or count
Smaller, softer, or atrophied testicles
Infertility

Energy & Recovery

Fatigue that is consistent throughout the day
Decreased endurance/stamina
Taking longer than usual to recover from exercise or physical labor
After lunch / mid-day "crash"

Other Physical Changes

Loss of body and facial hair (including general hair loss)
Hot flashes / Night sweats
Anemia
Joint pain
Muscle aches

Mood & Well-being

Depression (or feeling down)
Mood changes, moodiness, or irritability/grumpiness
Anxiety (or feeling anxious)
Decreased sense of well-being
Reduced motivation or lack of motivation
Trouble sleeping or Insomnia
Feeling timid or scared

Concentration & Memory

Difficulty concentrating
Mental fogginess or "brain fog"
Memory issues, more forgetful than usual, (or declining memory)
Not feeling as mentally sharp as I used to

Are there any other symptoms you want to tell us about?

Health & Medical

A few details about your health history to ensure your treatment plan is safe and effective.

Have you used hormone replacement medications before? If yes, please provide some basic details about your regimen, dosing, or protocol. *

*If this does not apply to you, simply put "NO".

Do you know how to self administer intramuscular or subcutaneous injections ? *

Please answer yes or no to every question.

	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
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

Are there any other health issues that you want the Physician to be aware of ? *

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

Current Medications *

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

Your Primary Care Physician *

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

Allergies - Please list any known allergies here *

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

What was your last known blood pressure reading ? *

Medical and Health History *

I want to improve my health and based on my own research I feel I can benefit from hormone replacement therapy, peptides, or weight loss medication..

Personal Information

Name *

First

Middle

Last

Address *

City *

State *

ZIP Code *

Date of birth *

Phone *

Age *

Approximately how tall are you ? *

Feet / Inches

How much do you weigh ? *

Ethnicity *

American Indian or Alaskan Native
Hispanic or Latino
Asian
White
Black or African American
Native Hawaiian
Patient Declines
Other

Marital status *

Married
Single
Divorced
Widowed

Sex *

Male
Female

What type of treatment(s) are you interested in ? *

Testosterone replacement therapy
HGH or Anti-Aging
Weight loss
Sexual enhancement
Peptide therapy
Vitamins and supplements

Today's Date *

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

Signature *

Clear Signature

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.

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.

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.

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

I agree

Today's date *

Name *

First

Middle

Last

Please sign here *

Clear Signature

HIPAA & PRIVACY

🔒 Promise of 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.

Your name *

First

Middle

Last

Address *

City *

State *

ZIP Code *

Phone *

Who are we authorized to share your information with ? *

(Ex. Spouse, Children, or put NONE

I authorize Superior Genetix to contact me by email regarding specific health related information. *

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 HIPAA 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 HIPAA Omnibus Rule, provides you this information with your knowledge and consent.

Notice of Non-Disclosure to Third Parties *

Superior Genetix maintains a policy of non-disclosure regarding the release of patient information to external entities (e.g., employers, insurance providers, or government agencies). I 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.

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

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

Today's date *

Please sign here *

Clear Signature

📸 Please Take A Picture Of Your ID

Identification Verification is Required For Prescribing Purposes.

Please upload an image of a valid state issued Photo I.D. **WE CANNOT PROCESS YOUR INTAKE WITHOUT THIS**

Drag & Drop Files, Choose Files to Upload

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

Please enter your driver's license number here. *

*This is required by Law for providing prescription medication.

Fee Acknowledgement & Agreement

One-Time Patient Intake Fee | Please Select One *

$300 - TESTOSTERONE REPLACEMENT THERAPY FOR NEW PATIENTS. This is a one-time clinic fee that covers patient enrollment, initial blood work required to begin treatment, medical charting, chart review, pre-appointment consultation, and your telehealth appointment with the Prescribing Physician.
$150 - WEIGHT LOSS & PEPTIDE THERAPY PATIENTS. This is one-time clinic fee that covers your patient enrollment, medical charting, chart review, pre-appointment consultation, and your telehealth appointment with the Prescribing Physician.This is required for most weight loss treatments, vitamins, and peptides.

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

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 us. You also understand that there can be no refunds or returns on prescribed medications, blood work, or medical prescriber consultations.

Please sign here *

Clear Signature

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

Once you click Submit, you're only 3 steps away from getting prescribed.

Please pay your invoice promptly so that we can get your blood work order to you TODAY.