Medical History Form

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Name

Address

Phone

Sex

Male

Female

Height

Weight

Date of Birth (MM/DD/YYYY)

What are your primary goals/desires/expectations from your treatment at HHWPB?

Do you have or have you ever had any of the following? (Mark all that apply)

Decreased memory

Increased wrinkles

Muscle loss

Decreased sex drive

Decreased desire or ability to exercise

Difficulty sleeping

Hot flashes/flushes

Lack of drive

Sagging muscles or breasts

Increased body fat

Mood swings

Loss of concentration

Decreased energy

Decreased endurance

Decreased sense of well being

Decreased muscle strength

Please List All Medications & Supplements, Drug Allergies & Past Medical History(including operations)

Family Medical History

Cardiovascular disease

Diabetes

Hypertension

Lipid disorder

Breast cancer

Prostate cancer

Other cancers

Other illness

Would you like improvement of libido / sexual function?

Yes

Do you have or have you ever had any of the following? If "yes" explain in area below.

Blood disorders

History of cancer

Drug allergies

Edema or excess fluid retention

Heart disease/attack

Hyperlipidemia or high cholesterol

Hypertension or high blood pressure

Immune disorders

Neurological disorders - thyroid

Endocrinological disorders including insulin resistance

Orthopedic or muscle disorders - fracture or joint disorders

Poor wound healing

Renal or kidney disease

If 'Yes' to any of the above please explain here:

Disclaimer: Please read and scroll all the way down before submitting the form below!

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In consideration of Hormone Health and Wellness of the Palm Beaches providing the undersigned patient with medical management, administrative and referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement. With this Agreement, Patient submits with this Agreement an accurately completed Medical History Form (MHF). Patient agrees to respond to truthfully, accurately and completely in completing the MHF and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to HHW or the physicians referred by HHW could result in inappropriate treatment.<br><br>Patient authorizes and HHW to obtain on my behalf medical laboratories, diagnostic testing, physicians and dispensing pharmacies. In addition, Patient authorizes and instructs HHW and physicians referred by HHW and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the MHF, laboratory diagnostic tests, and other information submitted to HHW under this Agreement. Patient agrees to present photo identification upon any blood testing pursuant to a HHW or Physician test requisition. Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by HHW, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.<br><br>Patient acknowledges that HHW employees and agents are not licensed physicians and that Physicians obtained on my behalf by HHW are independent contractors, which will be compensated by Patient with funds provided to HHW. Patient acknowledges that HHW does not practice medicine and that HHW is a medical management, administration and referral service and does not direct, control or influence the treatment decisions made by Physician. Patient further understands and agrees that HHW and Physicians are rendering the medical care, services and treatment and that HHW is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence. Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by Physician, to immediately cease any medical treatment prescribed by Physician in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide HHW and Physician with written notice via fax to HHW of any such adverse reaction or side affect. I further acknowledge and agree that HHW is not liable for any negligent act or omission of the Physician.<br><br>Patient acknowledges that diagnosis and treatment may involve risk of injury, and that HHW and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the hormone blood level objective sought as a result of Patients hormone replacement therapy, as prescribed by Physician, may be at the highest level of a standard reference range for Patients age and sex, or, in some cases, above such range, to the level of a younger person, and that such range is experimental and may not render any benefits, but may result in unknown, adverse results. Patient is aware of the nature, risk and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment. Patient acknowledges that recombinant human growth hormone replacement therapy involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician to administer such treatment to relieve body ailments and attempt to enhance Patients physical condition and health. Patient further acknowledges that the methods of medical treatment offered by HHW and Physician are not accompanied by any claims, guarantees, promises or warranties.<br><br>Patient is freely seeking medical consultation via the Internet and acknowledges and consents to Physician reviewing Patient's medical history without having the opportunity to conduct an in-person physical examination. Patient solicits HHW for a specific prescription medication to treat an already-identified medical or cosmetic condition. Patient acknowledges that Physician may not be licensed to practice medicine in Patients state or country of residence. Further, Patient agrees that Physicians consultations, diagnoses, and treatments will be deemed to have occurred in Florida, where physician is licensed to practice medicine.<br><br>Patient represents that he or she is under the care of a primary care physician and that Physician will not rely or substitute the advice of Physician should it conflict with the advice given to me by Patients primary care physician. Before taking any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone replacement therapy.<br><br>Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.<br><br>Patient acknowledges and agrees that HHW is not responsible for the negligent or intentional acts or omissions of any health care provider or supplier that Patient is referred or for any action or inaction taken by Patient, that the total liability of HHW, its officers, directors, employees, agents and stockholders is limited to the purchase price of any products through HHW, Physicians or pharmacies, and that HHW and Physicians will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. During Patients relationship with HHW and Physician, HHW and Physician will convey to Patient a range of proprietary business information, including, confidential disclosures and trade secrets business practices and HHW customers and suppliers. No matter how received by Patient during the parties relationship, Patient agrees that Confidential Information is confidential, proprietary and uniquely valuable to HHW and gravely affects the conduct of business of HHW and HHW goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any of Confidential Information or take any action that may result in disclosure of Confidential Information to any third-party person, firm, or business. Patient agrees that if the terms of this paragraph are breached, HHW shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any of the Confidential Information and to liquidated damages. Patient agrees that the amount of HHW actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty.<br><br>Based on the above-understanding, Patient agrees to release HHW, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physicians consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physicians consultation.<br><br>This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Palm Beach County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.<br><br>This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void and of no effect.<br><br>If any provision of this Agreement or the application thereof to any person or circumstances is held invalid or unenforceable in any jurisdiction, the remainder hereof, and the application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.<br><br>Patient covenants and agrees to indemnify, defend, protect and hold harmless HHW and Physician and their respective officers, directors, employees, stockholders, assigns, successors and affiliates from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paid by the Indemnified Parties in connection with, resulting from or arising out of, directly or indirectly, HHW and/or Physicians rendering medical care, services, advice, and/or treatment, Patients failure to disclose all relevant information regarding Patients medical and physical condition, acts or omissions of HHW or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by HHW or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties there from.

I agree to the terms of service and have completed the medical history form to the best of my knowledge. I certify that my answers are complete, honest and true.

Type Full Name

Today's Date

2025

Signature

Name

Address

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