New Patient Forms

🔒Secure Online Registration

🕒 Takes Approximately 5 Minutes

🪪 Photo of Your ID Required

Important: Once the intake form is submitted, you will receive a confirmation email. If you do not see a message from us in your inbox, please check your spam filter.

Let's Begin - Step 1 of 5

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.

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.
$200 - TESTOSTERONE REPLACEMENT THERAPY FOR PATIENTS SWITCHING CLINICS WHO HAVE RECENT BLOOD WORK. If you are currently being treated for low testosterone, you must email us a copy of your most recent blood work, and a copy/picture of your most recent prescription. Please email all required documents to: Sara.SuperiorGenetix@Gmail.com

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

ATTENTION PATIENTS SEEKING TESTOSTERONE REPLACEMENT THERAPY - CHECK LIST.

If you are providing us with your own blood work results, the labs needed to begin treatment are NOT negotiable. We require Total testosterone, CBC (Complete Blood Count), Estradiol, and PSA.
If you are coming from another clinic, or were previously diagnosed as having low testosterone, and you have blood work results and a prescription (current or recent) - please email that information to Sara.superiorgenetix@gmail.com IMMEDIATELY upon submission of this form. We need labs emailed in PDF format and a picture of the label on your prescription box is acceptable.
Please do NOT email us lab results that do not meet the necessary requirements. If you are unsure , it is best to pay the $300 fee and we will arrange your lab work for you.

*Incomplete intake forms will not be accepted

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.

New Patient Forms

🔒Secure Online Registration

🕒 Takes Approximately 5 Minutes

🪪 Photo of Your ID Required

📸 Optimizing Your Experience

Superior Genetix Health & Wellness, Inc. | Medical & Health History

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

HIPAA & PRIVACY

Fee Acknowledgement & Agreement