Medical History Form

Please complete the Medical History Form below. Please make sure your answers are accurate.
Your information will be stored on our secure server.
You will be contacted after this is completed by one of our Clinical Advisers.
* Required Fields

SECTION 1: Personal information

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ADDRESS

PHONE NUMBERS

OTHER

SECTION 2: Medical History

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GENERAL

PRIMARY PHYSICIAN INFORMATION

FAMILY HISTORY

Does an immediate family member currently have or ever had any of the following? If yes, please check below and explain in the provided field:

LIFESTYLE INFORMATION

DIAGNOSED HISTORY OF DISEASE

Do you currently have or ever had any of the following? If yes, please check below and explain in the provided field:

STEROIDS

Please select:

QUESTIONS FOR TREATMENT

Prospective Patients: Please check the symptoms you hope to improve through hormone replacement therapy (HRT).
Existing Patients: Please check the symptoms you have improved and hope to continue to improve through HRT.
NATIONAL HRT AND ITS PHYSICIANS DO NOT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT. We do not treat bodybuilders or professional athletes. We do not treat those who are currently in any branch of military service (active duty or reservist) or those who anticipate entering the military while taking any therapeutic program which may be prescribed for you. You must have a verified deficiency and medical need to qualify for treatment by our physicians.
Do you currently have or ever had any of the following symptoms? If Yes, please check and explain below:

SECTION 3: Signature

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Patient Authorization and Agreement

The undersigned Patient ("Patient") authorizes and instructs Kingsberg Medical ("Kingsberg Medical") to provide the Patient with medical management, administrative and referral services. Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement ("Agreement"). Patient submits with this Agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond truthfully, accurately and completely on the MHF and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to the physicians referred by Kingsberg Medical ("Physicians") could result in inappropriate treatment. Patient authorizes Kingsberg Medical to receive copies of reports from medical laboratories, diagnostic testing services, Physicians and dispensing pharmacies relating to his/her treatment. In addition, Patient authorizes and instructs Kingsberg Medical, Physicians and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the information contained on the MHF, laboratory diagnostic tests, and other information submitted to Kingsberg Medical under this Agreement. Patient agrees to present photo identification upon receiving any blood testing pursuant to a Kingsberg Medical or Physician test requisition. Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by Kingsberg Medical, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or any other insurance.

Patient specifically swears and acknowledges that he or she is not a professional or amateur athlete or bodybuilder. Patient specifically swears and acknowledges that he or she is not seeking treatment or prescription medication by Kingsberg Medical and/or Physician for the purpose of athletic or performance or cosmetic enhancement. It is outside the scope of Kingsberg Medical and the Physician to provide these services or prescriptions under those circumstances. Kingsberg Medical and the Physician only provide treatment and prescription medication to patients who have a deficiency and medical need as established by laboratory blood tests, physical examination, this MHF and in the sole determination of the Physician.

Patient acknowledges that Kingsberg Medical's employees and clinical advisers are not licensed physicians and that Physicians obtained on my behalf by Kingsberg Medical are independent contractors, which will be compensated by Patient with funds provided to Kingsberg Medical. I further understand and agree that Kingsberg Medical and Physicians are rendering the medical care, services and treatment, and that Kingsberg Medical 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 Kingsberg Medical and Physician with written notice of any such adverse reaction or side effect. I further acknowledge and agree that Kingsberg Medical is not liable for any negligent act or omission of the Physician.

Patient acknowledges that diagnosis and treatment may involve risk of injury, and that Kingsberg Medical 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 Patient's hormone replacement therapy, as prescribed by Physician, may be the highest level of standard reference range for Patient's 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 and being utilized 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 deficiencies. Patient further acknowledges that the methods of medical treatment offered by Kingsberg Medical and Physician are not accompanied by claims, guarantees, promises or warranties. In compliance with federal and state laws, there will be no refund given for any medication.

Patient is freely seeking medical consultation via the internet and acknowledges and consents to Physician reviewing Patient's medical history without the opportunity to conduct an in-person physical examination. Patient has contacted Kingsberg Medical for a specific prescription medication to treat an already-identified medical condition. Patient acknowledges that Physician may not be licensed to practice medicine in Patient's state or country of residence. Further, Patient agrees that Physician's consultations, diagnosis, and treatments will be deemed to have occurred in Florida.

Patient represents that he or she is under the care of a primary care physician and the Physician, and he or she will not rely or substitute the advice of Physician should it conflict with the advice given by Patient's primary care physician. Before qualifying for any treatment or any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination and to submit same to become a part of patient's records to be maintained by Kingsberg Medical. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone replacement therapy.

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 Broward 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.

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. If any provision of the 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.

Patient covenants and agrees to indemnify, defend, protect and hold harmless Kingsberg Medical and Physician 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, demand, 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, Kingsberg Medical 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, may result in acts or omissions by Kingsberg Medical or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Kingsberg Medical 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 herein.

Liability Waiver and Hold Harmless: I voluntarily choose to undergo hormone replacement therapy. All potential risks and side effects have been fully explained to me. I acknowledge and understand those risks. I have assessed the risk on a personal basis, and my personal belief is the benefits of hormone therapy out weighs the risks (including the possibility of raised prostate levels which some physicians think could possibly lead to prostate cancer). I hereby release and agree to hold harmless Kingsberg Medical, the entire Staff at Kingsberg Medical and the prescribing Physician associated with my hormone replacement therapy. I have had adequate time to consider all options and research hormone replacement therapies. This agreement shall serve as release and hold harmless and is binding on behalf of myself, my heirs, assignees, designees, and personal representatives.