New Patient Intake Form
This agreement between (“Patient”) and Prime Anti-Aging establishes guidelines and conditions for the use of IV vitamin and hydration therapy. Prime Anti-Aging and patients agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution. The patient agrees and accepts to the following conditions:
- I understand that the vitamins I am receiving are based on my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions in accordance with applicable State and Federal law.
- I certify that the answer I provided to the health questions on the health history. laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
- I do not have a history of diabetes, congestive heart failure or any other type of heart disease.
I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effects related to my treatment to Prime Anti-Aging and discontinue use until advised to resume usage by my healthcare provider. I voluntarily assume any and all possible risks which may be associated with IV hydration therapy.
- I understand that representatives of Prime Anti-Aging and/or licensed Physician’s Assistant are available for questions during normal business hours throughout the course of my treatment.
- I understand that IV hydration therapy is not covered by health insurance. I agree that all services and medications provided by Prime Anti-Aging or its associated providers are to be paid in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third-party
- I agree that Prime Anti-Aging/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Prime Anti-Aging will be in conjunction with the care provided by my current PCP.
- I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
- I have read and agreed to the terms of this therapy management agreement.
I consent to text and email message appointment reminders *Data rates may apply. This agreement between (“Patient”) and Prime Anti-Aging establishes guidelines and conditions for the use of hormone replacement therapy (“HRT”) involving DEA controlled or scheduled medications. Prime Anti-Aging and Patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and, therefore, these agents are prescribed with caution.
The patient agreed and accepts to the following conditions:
- I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, and the results of lab work and physical examination. The medications are to be used exclusively for treatment of hormonal deficiencies and related medical conditions in accordance with applicable state and Federal laws.
- I understand and agree that no medical treatment or medication provided to me by Prime Anti-Aging will be used for the purposes of bodybuilding, performance enhancement, or physical appearance.
- I certify that the answers I provided to the health questions on the health history laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
- I will not attempt to obtain HRT medications from any other healthcare practitioner without disclosing my current medical usage or HRT or other medications. I understand that it may be against the law to do so.
- I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side effects related to the use of my HRT to Prime Anti-Aging and/or a licensed physician’s assistant are available for questions and/or concerns during normal business hours throughout the course of my treatment.
- I agree that the HRT medications furnished by Prime Anti- Aging are for my personal use and for no other purpose. I will not share, sell, or trade my medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
- I will be able to purchase the medications from the pharmacy designated by Prime Anti-Aging and the pharmacy will send medication directly to me. I understand that I have the right to purchase my medications from any pharmacy of my choice. If I chose to obtain medications from a pharmacy of my own choice, I must notify Prime Anti-Aging in writing of my intention to do so and include the name of the pharmacy in my request.
- I agree and understand that federal regulations prohibit the return of prescribed medications.
I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Prime Anti-Aging or its associated providers are to be paid in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third-party payer.
10. I agree that Prime Anti-Aging patient/physician relationship is not intended to replace the existing patient/physician relationship with my primary care provider (PCP) and the treatment provided by Prime Anti-Aging will be in conjunction with the care provided by my current PCP.
11. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective, labeled container.
12. I understand that Prime Anti-Aging only treats patients over the age of 30 with documented symptoms of hormone deficiencies (hypogonadism and adult growth hormone deficiency No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current health history through either the patient’s personal physician or progressive health institute-affiliated physician. Agreeing to lab work does not automatically qualify a patient to clinical necessity and prescription of HRT.
I consent to text and email message appointment reminders.
