TRT New Patient Intake Form - Superior Genetix Health and Wellness

Let's Begin - Step 1 of 3

What is your email address ? *

Confirm Email

*This email will be used for important correspondence related to your treatment. This is the only email we will ever use to correspond with you regarding your treatment.

How did you learn about us ? (Ex. Referred, google search, forum etc.) *

Where you referred to us ? If so, please provide the name of the person who recommended us.

Are you switching to us from another TRT provider ?

If Yes, please provide the name of your previous prescriber or clinic.

Superior Genetix Health & Wellness, Inc.

Telehealth Patient Intake Form

Health | Medical | Symptoms

Name *

First

Middle

Last

Address *

City *

State *

ZIP Code *

Phone *

Date of birth *

Age *

Approximately how tall are you ? Feet/Inches *

How much do you weigh ? Lbs. *

Occupation *

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

*If you are unable to upload, please email us an image of your license or valid state I.D. *Proper identification is required by law for all prescription medications and lab work. Email to: Sara.superiorgenetix@gmail.com.

**IF YOU DO NOT UPLOAD YOUR IDENTIFICATION, YOU MUST EMAIL US A COPY OF YOUR DRIVER'S LICENSE OR STATE I.D. *

Yes, I am emailing my driver's license/state i.d. once I complete this form. I understand that if I do not email my driver's license or state i.d. my intake WILL NOT BE PROCESSED.

Please enter your driver's license number here. *

*This is required by Law for providing prescription medication.

Your Primary Care Physician *

Please provide us the name of your primary care doctor or other health care provider. We will NOT share any information with them. This is only for our records.

Ethnicity *

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

Marital status *

Married
Divorced
Widowed
Separated
Single (never married)

Sex *

Male
Female

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..

Hypertension *

Heart Disease *

Stroke *

Autoimmune *

Diabetes *

High cholesterol *

Obesity *

Cancer *

COPD/Asthma *

Prostate/BPH *

Gastrointestinal *

Hormone disorder *

Allergic reaction *

Current Medications *

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

Allergies - Please list any allergies here *

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

Are there any health conditions that you need to make the physician aware of ? *

If you have no health conditions to report, please put "NO".

What was your last blood pressure reading ? *

What Low Testosterone Symptoms Are You Experiencing ?

*Please check all that apply.

Physical Symptoms

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 (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

Cognitive & Emotional Symptoms

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 are experiencing ? *

Enter "NO" if you have no additional symptoms.

If you have ever used testosterone, please provide your dose, response, and tolerance to the medication. *

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

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

Do you regularly use tobacco ? *

Do you regularly consume alcohol ? *

Do you regulary use recreational drugs ? *

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

Today's Date *

Signature *

Clear Signature

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. I acknowledge that Superior Genetix may recommend products or services to me that may improve treatment outcomes, and that the clinic may or may not receive third party remuneration from these affiliated companies.

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. I agree that Superior Genetix does not "co-treat" patients for testosterone replacement therapy, and they are not permitted to share patient information directly to anyone other than "the patient".

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 Superior Genetix does not accept insurance, Medicare, or Medicaid. I agree that if I use insurance for any lab-work or treatments, that Superior Genetix is not responsible for any portion insurance may not cover.

8. Price Transparency, Fees, and Costs

There are NO membership fees and no hidden costs. The patient is responsible for the cost of medication(s), shipping, and blood work. The price of medication and lab work includes administrative costs. Patients are NOT obligated to order blood work with the clinic if they have access to a lower cost. Any third party lab work must meet the compliance of the prescribing physician.

Today's date *

Name *

First

Middle

Last

I acknowledge that I have read and understand all the terms outlined in lines 1-8 above. *

I agree

Please sign here *

Clear Signature

🔒 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.

Who are we authorized to share your information with? *

(Example: Spouse name, relative name, , or put NONE

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.

I authorize Superior Genetix to contact me via email or text message regarding health-related information. This includes, but is not limited to, appointment reminders, clinical requests, and other necessary treatment-related correspondence. *

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

*Patient acknowledges that they have read and understand the privacy practices, consent/limited authorization, and release form.

Today's date *

Your name *

First

Middle

Last

Please sign here *

Clear Signature

Fee Acknowledgement & Agreement

$300 One-Time Only Clinic Onboarding Fee Provides You LIFETIME ACCESS To All Available Medications. *

This this one-time only fee covers onboarding coordination associated with your enrollment, medical charting, case review, your initial medically compliant blood work (which we coordinate on your behalf), diagnosis, pre-appointment telephone consultation (giving you 30 minutes of direct clinical interaction), development of a treatment plan, and the telehealth appointment with the prescribing physician.

* This is a one-time clinic intake fee. You will receive an invoice by email for this transaction.

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.

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 an invoice for the one-time clinc intake fee