Enter your email address to get started:
First Name:
Last Name:
Phone Number:
Date of Birth (MM/DD/YY):
How did you hear about us?
Street Address:
City:
State:
Zip Code:
Name on Driver's License:
Driver License Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Please Upload a Picture of your Driver's License:
Height:
Weight
Consent for Treatment My signature below is to certify I have read this consent. I understand I will receive an oral explanation combined with documents of my treatment plan. If I consent to the treatment plan(s) prescribed to me by MedTech’s physicians and staff, I understand and accept that additional costs may be incurred by me and I am solely responsible for these expenses. I understand that I may ask further questions at any time. I understand that I may stop treatment at any time.
Nature of Treatment: I hereby give my consent to evaluation and treatment by MedTech Practice Management Physician’s of the following specified conditions: *
Other hormonal imbalances/Obesity, please specify If applicable:
I agree to the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals, and antioxidants and/or drugs designed to alter hormone levels, all specific to my diagnosis, particular condition, and treatment objectives.
I understand the reasonable alternatives to this treatment are leaving hormone levels as they are, treating age related diseases as they appear, and using pharmaceutical agents that are not bioidentical in nature (synthetics).
I understand the foregoing alternatives and I am choosing to consent to the treatment plan prepared for me by MedTech Practice Management and Physicians to address the condition(s) indicated above.
I understand that the possible side effects for men on testosterone replacement are acne, persistent erections, unwanted hair growth, increased risk of blood clots, heart attack, stroke, enlargement of prostate, enlargement of breast tissue, and testicular atrophy (shrinking).
I understand the possible benefits associated with therapy but that no guarantee has been made to me regarding outcomes of this treatment. I also understand that the benefits derived from antioxidant therapy will cease and those derived from hormone therapy and drugs that alter hormone levels will reverse if the therapy is discontinued.
I understand that I will consult with my primary care physician for any other medical services I may require. I understand that this is a specialized practice. I understand that I will continue under the care of my other physician(s) for any on-going medical condition as well for any medical consultation I may need.
I assume full liability for any adverse effect that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the therapy, except as that claim pertains to negligent administration of the therapy.
I fully understand the nature and purpose of the aforementioned treatment may be considered experimental because of the lack of adequate scientific evidence or peer-reviewed publications supporting the underlying premise of bioidentical hormone replacement therapy and that such therapy might even be considered by some medical professionals to be medically unnecessary because it is not aimed at treating a particular disease.
I hereby give my consent to this agreement by signing below:
I understand that the possible side effects for women on estrogen, progesterone, and/or testosterone include breast swelling and/or discomfort, fluid retention, dizziness, break through bleeding, acne, unwanted hair growth, headaches, increased risk blood clots, and worsening of (1) Ovarian cysts, (2) uterine fibroids, (3)endometriosis, and (4) fibrocystic disease.
I understand that if I become pregnant, I should stop the entire treatment protocol immediately and notify my physician. I understand that this hormone therapy is not for the purpose of preventing pregnancy, and that if I become pregnant on this therapy it could present risk to the fetus (unborn child).
I understand that I will be responsible for administering the medications prescribed to me. I will comply with recommended dose and methods of administration. I also agree to participate in the initial and subsequent hormone testing, as required, to monitor my hormone levels.
Your Health History, Please Check all that apply:
Please verify your gender once more:
Please check all symptoms you have experienced in the last 6 months.
Please sign to acknowledge you understand your rights and this agreement and consent to treatment.
Please check all symptoms that you have experienced in the last 6 months (women):
Health History & Medical History Acknowledgement: Please sign to acknowledge you understand your rights and this agreement and consent to treatment. *
Medtech Practice Management LLC, established guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA controlled or scheduled medications.
The patient accepts and agrees to the following conditions:
The guidelines and conditions set by MedTech Physicians are an essential factor in maintaining a successful patient/practitioner relationship.
The medication(s) prescribed for me are based on diagnosis derived from my submitted medical history, lab work, and physical exam. They are to be based exclusively for treatment of these diagnoses.
I will immediately report any adverse side effects related to the use of my medication to MedTech Practice Management and discontinue use until advised to resume usage.
I will safeguard my medications from loss or theft.
I will not share, sell, or trade my medication for money, goods or services.
I agree that I will use my medication at the prescribed rate and dosage, and will keep the medications in its respected labeled container.
I will not attempt to obtain scheduled HRT medications illegally from any other health care practitioner without disclosing my current medication usage. I understand that it is against the law to do so.
Prescription Medication Agreement - Please sign below: *
Our notice of privacy practices information about how we may use or disclose protected health information.
The notice contains a patients rights section describing your rights under the law you ascertain that by your signature that you have reviewed our notice signing this consent.
The term of the notice may change, if so you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclose for treatment, payment or healthcare operation. We are not required to agree with the restriction, but if we do, we shall honor the agreement. The HIPAA (Health insurance portability and accountability act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication have the right to revoke this consent in writing, signed by you however, such a revocation will not be retroactive.
by signing this form ,I understand that:
HIPAA Compliance Agreement: Please Sign Below: *
We use a HIPAA compliant EMR (electronic medical record) system for documenting all communications, treatment plans, patient notes, documents and labs. Our system sends treatment reminders, notifications and updates through text and email. Please acknowledge you understand we use phone calls, electronic mailing and texting to communicate with you regarding treatment.
Communication Consent: Please Sign Below
MedTech Practice Management will charge all fees accrued from labs to treatment plans. We will never charge for a refill without authorization from text, email or verbal communication with each and every refill. By signing below, I authorize MedTech Practice Management to charge my credit card for agreed upon services. I understand that my information will be saved to file for future transactions on my account.
Payment Authorization; Please sign below:
MedTech Practice Management is a non-diagnostic preventative health care provider. Our doctors and staff directly prescribe all required tests and review and confirm all test results. We may also validate and verify submitted medical information. Patients who are found to have signs and symptoms of legitimate medical and/or health conditions are advised to speak to a medical specialist. MedTech Practice Management reserves the right to recommend and use internal and/or external medical specialists for any patient and all patient information will be protected under all HIPPA laws and regulations. MedTech Practice Management is not an internet pharmacy and does not dispense, ship,or distribute medications from our facility or web sites. Any and all medication prescribed by our doctors for medical treatment will be dispensed from a US FDA approved pharmacy compound. All patients are required to fulfill and follow all of the medical instructions and procedures prescribed by the doctor and contact us immediately if they have any problems, questions, or concerns. Patients who are found to have submitted fraudulent information will be terminated from any health program offered by MedTech Practice Management. Any medication prescribed is only for the use of the patient and is not to be transferred, distributed, modified, or used by any other party.
MedTech Patient Management LLC. (“MedTech”) providing the undersigned patient (“Patient”) with medical management, administrative and referral services, the patient acknowledges and agrees to the following terms and conditions contained in this patient authorization agreement. With this agreement, the patient submits an accurate completed medical history form. Patient agrees to respond truthfully, accurately and completely in completing all documents sent by MedTech. Patients acknowledge that failure to provide truthful, accurate and complete information in documents could result in inappropriate treatment.
Patient authorizes MedTech Practice Management to obtain on my behalf any medical laboratories, diagnostic testing, physicians and dispensing pharmacies. In addition, patient authorizes and instruct MedTech and physicians referred by MedTech (“physicians”) and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the documents I have filled out from MedTech, laboratory diagnostic tests, and other information submitted to MedTech under this agreement. Patient agrees to present a photo identification upon any blood testing pursuant to a prescription or physician test requisition. Patients acknowledge that therapies, laboratory and diagnostic testing services provided to me by MedTech and MedTech physicians are not covered or reimbursed by Medicare or other insurance.
I further understand and agree that MedTech and MedTech Physician’s are rendering medical care, service and treatment. I understand that MedTech and physician’s are instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by a pharmacy in my country of residence. Patient covenants and agrees to comply with the method of instructions, treatment, and dosage schedules prescribed by the physician, to immediately cease any medical treatment prescribed by the physician in the event of any adverse reaction or side effect arising from prescribed treatment. Patient agrees to immediately provide MedTech with written notice via email, or text through a secure EMR system of any such adverse reaction or side effect. Patients acknowledge that diagnosis and treatment may involve risk of injury, and that MedTech and MedTech physician’s have made no guarantees or warranties with respect to the above described diagnostic testing analysis of test results, examination of medical history provided or hormone treatment.
Patients are aware of the nature, risk, and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment, peptides, vitamin injections, amino acid injections and medicated weight loss.
Patients acknowledge that human chorionic gonadotropin involves the use of a medical drug approved for one purpose, for a new different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, the patient consents to such care and treatment, and executes this agreement with a complete and informed understanding of such hormone replacement therapy for the purpose of authorizing physicians to administer such treatment to relieve body ailments and attempt to enhance patients physical condition and health.
Patients acknowledge that the methods of medical treatment offered by MedTech and MedTech Physician’s are not accompanied by any claims, guarantees, promises or warranties. It is fully agreed and understood by the patient that products purchased from MedTech require a medical prescription and such are NOT returnable or refundable under any circumstance under both Federal and/or State laws. It is unlawful for a pharmacy to accept the return of prescription medications once they have left the control of the pharmacy.
Patient acknowledges that and agrees that MedTech 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 MedTech, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through MedTech, MedTech Physicians, or Pharmacies. MedTech and MedTech Physicians will not be liable for any direct or indirect, special, consequential, or punitive damages.
During Patient’s relationship with MedTech and MedTech physician’s, MedTech and MedTech Physician’s will convey to patients a range of proprietary business information, including confidential disclosures and trade secret business practices and MedTech customer and suppliers (“confidential information”). No matter how received by the patient during the parties’ relationship, the patient agrees that confidential information is confidential, proprietary and uniquely valuable to MedTech and gravely affects the conduct of business of MedTech Practice Management LLC and MedTech’s goodwill. Patient agrees to not disclose, divulge or communicate, in any fashion, form or manner, either directly or indirectly, any confidential information or take any action that may result in disclosure of confidential information to any third party person, firm, or business.
Based on the above understanding, Patient agrees to release MedTech Practice Management, its Physician’s, officer, directors, employees, agents and shareholders from any and all liability associated with or arising from the physician’s 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 Physician’s consultation.
Patient acknowledges that he/she is responsible for rendering payment for any agreed upon treatment components between patient and MedTech Practice Management. Patients understand that restoring and balancing hormones accurately requires follow up blood work and monitoring. These follow-ups may require additional costs for the patient. Failure to submit to required testing and follow-up procedures as determined by the discretion of the physician on staff may result in discontinuation of treatment until therapy requirements have been received by MedTech. Patient understands that he/she will not be refunded for any lab orders or appointments once the service is provided, even if he/she does not qualify for treatment as initially intended. The patient understands he/she will not receive a refund for any medications once they have been dispensed from the pharmacy. Once medication leaves the pharmacy it can not be returned.
This agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made andr to be made and to be performed entirely with 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 state of Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceding arising out of, in connection with or with respect to this agreement. In the event of litigation arising out of this agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorney’s fees and legal assistants’ fees.
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.
Any provision of this agreement or the application thereof to any person or circumstance is invalid or unenforceable in any jurisdiction, the remainder hereof, and all 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 the agreement shall be severable.
Patient covenants and agrees to indemnify, defend and hold harmless MedTech Practice Management, their Physicians, and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (“indemnified parties”) from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigations, demands, judgements, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained or incurred or paid by indemnified parties in connection with with, resulting from or arising out of, directly or indirectly, MedTech Practice Management and/or Physician’s rendering medical care services, advice and/or treatment, Patient’s failure to disclose all relevant information regarding patient’s medical and physical condition, acts of omissions of MedTech or physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by MedTech 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 therefrom.
The undersigned acknowledges and agrees that the services provided by MedTech Practice Management are non-covered, self-pay services in all instances. The undersigned warrants and represents to MedTech Practice Management that he/she will not submit an claims or invoices for services furnished by MedTech Practice Management or its affiliates to any insurer, payer, or claims administrator, or utilize any health savings accounts funds in violation of the rules applicable to such health savings account.
Payment Authorization Agreement; Please Sign Below:
I hereby attest to the following:
Client has executed this acknowledgment under their own free will. MedTech Practice Management (the “Company”) has not exerted any undue pressure or influence on Client in this regard, nor has the Company offered any incentive for Client to execute this acknowledgement. Client has had reasonable time to review and understand this acknowledgement.
Client acknowledges and verifies that Client contacted Company unilaterally for their services. Client wishes to obtain Company’s services including, but not limited to: [SERVICES].
Client acknowledges and verifies that Company has not directly or indirectly, solicited, communicated with or otherwise contacted Client, for the purpose of providing services sought by Client referenced in Section 2 above.
Client has read the acknowledgement, agrees with all provisions contained therein, and signifies their acceptance of such acknowledgment by their signature below.
Client Acknowledgement Form; Please Sign Below: