agreed and accepts to the following conditions: 1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6.1 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.
7. 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.
8. I agree and understand that federal regulations prohibit the return of prescribed medications.
9. 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.