Disclosure/Liability Waiver

Padgett Medical Center, LLC – Bio-Identical Hormone Replacement Program

While numerous safety measures are taken by our physicians and staff, incidental events may occur that are beyond the control of our physicians or staff. Within the medical community, there are opposing. views with respect to the use of bio-identical hormonal replacement therapies. The use of bio-identical hormones does provide true medical benefit, and is being used at our center to lessen/treat non-life threatening symptoms you have identified as bothersome, undesirable. and frankly unwanted. It is therefore expressly agreed that you are voluntarily participating in this program and all bio-identical hormonal replacement regimens, and the use of any medications and/or supplements is undertaken at your own risk. You are voluntarily participating in this program and assume all the risks of injury to yourself that might result. You hereby agree to waive any claims or rights you might otherwise have to pursue legal remedies from Padgett Medical Center, LLC, it's staff, or treating providers for injury to you on account of involvement in the Bio-identical Hormone Replacement Program. You have carefully read this waiver and fully understand it is a release of liability.

I accept all terms and conditions of this program.

HIPAA Release of Information Authorization Form

Patient authorizes Padgett Medical Center, LLC to request any and all medical records, x-rays, or any diagnostic testing results from any and all medical providers involved in my medical care past or present. Please forward any and all documents requested to the attention of the provider at this fax number below.

Tampa office Fax (813) 908-7711

Ocala office Fax (352) 369-0107

By signing this authorization, I understand that medical records released may contain
information related to HIV status, aids, sexually transmitted diseases, mental health, and alcohol abuse, etc. I understand that release of psychotherapy notes requires additional authorization. NOTE: If the information you are authorizing for release by signing this form involves alcohol or drug abuse, you must also sign a special authorization that is separate from this one, alcohol and drug abuse information is protected by federal law (FEDERAL REGULATIONS 42 CFR PART 2) and will not be shared with anyone else unless you sign a separate form.

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I understand that Padgett Medical Center, LLC is using information which I am providing about my blood pressure and current health conditions to provide medical services. I agree to provide accurate information to the best of my knowledge. In the event that I experience medical complications due to my blood pressure or other medical history that was not properly disclosed to Padgett Medical Center, LLC, I assume full responsibilty for all health conditions that may arise. I agree to hold Padgett Medical Center, LLC, all staff, physicians, and mid-level providers harmless. I release all liability from Padgett Medical Center, LLC for any adverse medication reactions that may arise. I understand that temporary provisions allow services to be completed via telemedicine. I understand that future visits I will be required to visit in person and complete any necessary testing as requested by medical providers.