Basis Male Intake Form

Male Intake Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthdate*

MonthDayYear
Date
Age*
Occupation*
How did you hear about us? Please specify with referral source name.*
Height*
Current Weight*
Goal Weight*
Emergency Contact:name* Relationship: relationship*
Emergency Contact Phone Number *
Please enter a valid phone number.
Marital Status:*

SingleMarriedDivorcedWidowedDomestic Partner
Do you have kids? If so, what ages?
Primary Physician:blanks Date of Last Visit: blank
List your primary symptoms of concern you want to address by priority
IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING:

I certify the information provided is true and correct and that I am a competent adult of at least 18 years of age, or that I am a minor, under the age of 18, I understand that the consent of my parent/guardian/person having legal custody will be required before treatment. FURTHER, I UNDERSTAND A CONSULTATION IS PROVIDED BY THE PHYSICIAN'S APPOINTED NON-MEDICAL REPRESENTATIVE AND IS STRICTLY TO PROVIDE PROGRAM/TREATMENT INFORMATION.
Signature*

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Date*

MonthDayYear
Date

This agreement between blanks* ("patient) and Basis Medical LLC("BM") establishing guidelines and conditions for the use of hormone replacement therapy ("HRT") involving DEA "controlled" or "scheduled" medication. BM 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 agrees 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 Law.
2.I understand and agree that no medical treatment or medication provided to me by Basis Medical LLC will be used for the purpose of body building, 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 of HRT or other medication. 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 effect related to the use of my HRT to Basis Medical,LLC and discontinue use until advised to resume usage by Basis Medical. I voluntarily assume any and all possible risks which may be associated with HRT.
6.I understand that representatives of Basis Medical and/or Licensed Physician Assistant are available for questions and/or concerns during normal business hours throughout the course of my treatment.
7.I agree that the HRT medications from the pharmacy designated by Basis Medical are for my personal use only 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.
8.I will be able to purchase the medications from the pharmacy designated by Basis Medical and the pharmacy will send medication directly to me. I understand I have the right to purchase my medication from any pharmacy of my choice. If I choose to obtain medication from a pharmacy of my own, I must notify Basis Medical in writing of my intentions do so and include the name of the pharmacy in my request.
9.I agree and understand that the federal regulations prohibit the return of prescribed medications.
10.I understand that HRT treatments are not covered by health insurance. I agree that all services services and medication provided to me by Basis Medical or its associated providers are to be paid for in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid or other third party payer.
11.I agree that the Basis Medical patient/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Basis Medical will be in conjunction with the care provided by my current PCP.
12.I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
13.I understand that Basis Medical 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 consultations, and current health history through either patient's personal physicians or a Basis Medical - affiliated physician. Agreeing to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.
I have read and agree to the terms of this Therapy Management Agreement.
Initials*
Today's Date*

MonthDayYear
Date

Notice of Privacy Practices - Acknowledgement & Consent (Consent to use PHI)

Acknowledgement for Consent and Use and Disclosure of Protected Health Information
Use and Disclosure of your Protected Health Information

Your Protected Health Information will be used by Basis Medical, LLC or may be disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic informatiom, collected from you and created or recieved by this office. You may review the notice prior to signing this consent. You may request a copy of the Notice at the Front Desk.

Requesting a Restriction on the Use or Disclosure of Your Information

-You may request a restriction on the use of your Protected Health Information.

-This office may or may not agree to restrict the use or disclosure of your Protected Health Information.

-If we agree to your request, the restriction will be binding with this office. Use of disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occured prior to the date on which your revocation of consent is received will not be affected.
Initials*
Date*

MonthDayYear
Date
Provider's Signature

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Authorization of Care
This clinic will attempt to identify and diagnose any ailments you may have that may be corrected through physical medicine, massage therapy, chiropractic care, and/or active/passive rehabilitation. If any condition or disease appears to be present out of our scope of practice ,we will refer you to an appropriate physician to diagnose and/or treat that condition. The clinical procedures performed are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not providespecific healthcare if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known these things which otherwise might not come to the attention of the physician (deformities, illness, etc.). I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or not, by binding arbitration under the current malpractice terms which can be obtained by written request.

I also clearly understand that if I do not follow the Doctors and/or physician's specific recommendations at this clinic that I will not receive the full benefit from these programs, and that if I terminated my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor and/or physician for all services rendered. I understand in the event my account goes to collections, I am responsible for any and all collection fees.

I understand that I am financially responsible for all fees incurred for the services provided, regardless of any applicable insurance or benefit payment, and I agree to ensure full payment. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereny authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy and/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions.
Name of Guarantor (person responsible for guaranteeing payment for all services) blanks*
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.
Patient's Name Printed*

First NameLast Name
Date*

MonthDayYear
Date
Patient's Signature*

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Minor's Full Name

First NameLast Name
Guardian/Spouse's Signature of Authorizing care for Minor (I hereby authorize Basis Medical, LLC to administer care as deemed necessary my child, a minor under the age of 18 years old)

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Emergency Contact
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Should be Empty:

	Child	Siblings	Father	Mother	Self	N/A
Abnormal Blood Pressure
Asthma/Bronchitis
Autoimmune Disease
Blood Disorders/Anemia
Cancer/Tumors/Cysts
Depression/Mental Illness
Diabetes
Endocrine Disorder
Gallstones
Heart Disease
Herpes/Cold Sores
High Cholesterol/Lipids
Hepatitis
Jaundice/Liver Disease
Phlebitis/Varicose Veins
Thyroid Disease
Seizures
Ulcers

	0=NEVER	1=SOMETIMES	2=REGULARLY	3=OFTEN	4=CONSTANTLY
Hair Loss on Top of Head
Depressed
Swollen Belly
Irritable & Aggressive Behavior
Loss of Self Control
Restless, Light Sleep
Anxious
Face Wrinkled & Slack
Loss of Muscle Tone
Increased Belly Fat
Fatigues, Feeling Exhausted
Reduced Libido
Memory Lapses/Mental Fog
Weight Gain (Hips,Waist,Thighs)

	0	1	2	3	4	5	6	7	8	9	10
Current Level of Back Pain
Current Level of Joint Pain
Stress Level Past 30 Days
Stress Level Past 6 Months
Energy Level in Morning
Energy Level in Late Afternoon

Male Intake Form

List your primary symptoms of concern you want to address by priority

IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING:

I have read and agree to the terms of this Therapy Management Agreement.

Notice of Privacy Practices - Acknowledgement & Consent (Consent to use PHI)

Authorization of Care

Emergency Contact