Getting Started With HRT at Superior Genetix

Thank you for trusting us to be your guide on the path to looking and feeling your absolute best.

We would like to take a moment to provide you with some details on your client intake process.

The Process Is Simple

• Fill out the required medical forms below. This only takes about 2 minutes.
• We will send you a confirmation email and notify you where to get your blood work done. No appointment is necessary.
• The results of your blood work are emailed to the Superior Genetix Pescribing Physician/Practitioner for review.
• The Physician/Practitioner will call you to provide the details of your treatment.
• Your treatment/medications will be mailed directly to you. You will receive a tracking number via email so that you can track your order.
• Your prescription(s) will renew automatically as scheduled, and you will be billed ONLY for the prescription cost. 

Ready To Get Started ?

Let's Begin - Step 1 of 3

What is your email address ? *

Email

Confirm Email

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

Were you referred to us ?

*We like to show appreciation to those who refer us, so please let us know how you heard about us.

Next

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

Please complete the form below

Name *

First

Middle

Last

Address *

Address Line 1

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Date of birth *

Age *

Approximately how tall are you ? *

How much do you weigh ? *

Your Primary Care Physician *

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

Occupation *

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. If you are unable to upload, please email them to us.

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

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 *

• yes
• no

Heart Disease *

• yes
• no

Stroke *

• yes
• no

Autoimmune *

• yes
• no

Diabetes *

• yes
• no

High cholesterol *

• yes
• no

Obesity *

• yes
• no

Cancer *

• yes
• no

COPD/Asthma *

• yes
• no

Prostate/BPH *

• yes
• no

Gastrointestinal *

• yes
• no

Hormone disorder *

• yes
• no

Allergic reaction *

• yes
• no

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 regularly use tobacco ? *

• yes
• no

Do you regularly consume alcohol ? *

• yes
• no

Do you regulary use recreational drugs ? *

• yes
• no

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

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

Tell us about the symptoms you are experiencing (ex. weight gain, fatigue etc.) *

*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 *

• Yes

Signature

Clear Signature

Next

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. The physician has your informed consent for treatment through telehealth remote examination.
• 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.

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 *

Clear Signature

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

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

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 regarding specific health related information via: *

• Cell phone
• Home phone
• Work phone
• Email
• Text

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. *

• Yes

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 *

Clear Signature

Fee Acknowledgement & Agreement

Intake Fee | Please Select One *

• $300 - Clinic Fee, Blood Work Fee and Physician Fee. (Required for Testosterone) This is a one-time payment that covers patient enrollment, blood work/labs, medical charting, chart review, pre-appointment consultation, and your telehealth appointment with the Prescribing Physician. If you have blood work less then 6 months old that include CBC and Testosterone level, please email them to us upon completion of this application for a $100 reduction of this cost.
• $150 - Clinic Intake and Physician Fee. (Required for Weight Loss Treatments and Peptides) This is a one-time payment 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. If you're seeking Testosterone or other hormone replacement, blood work is required, and you will need to select the $300 option.

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

Please Check Any That Apply

• I am transferring to Superior Genetix from another clinic.
• I was referred to Superior Genetix.

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 *

Clear Signature

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

Submit