The patient comprehends that the medications received or to be received are prescribed exclusively based on diagnoses derived from the patient's submitted medical history, along with the outcomes of laboratory assessments and a physical examination. These medications are to be used solely for addressing hormonal deficiencies and associated medical conditions, consistent with the relevant state and federal laws.
The patient acknowledges and agrees that no medical treatment or medication provided by Warriors Weightloss shall be employed for the purposes of bodybuilding, performance enhancement, or enhancing physical appearance.
The patient affirms that the responses provided to health-related queries on the Health History form, as well as any information conveyed to Warriors Weightloss -affiliated physicians or laboratories, are truthful and accurate to the best of their knowledge. The patient confirms that they have not received coaching from any third party and have not engaged in any deceptive practices for personal gain, particularly with regard to medical treatment or medication prescriptions.
The patient commits not to seek HRT medications from any other healthcare practitioner without disclosing their current use of HRT or other medications. The patient understands that this may constitute a violation of the law.
The patient acknowledges that they have discussed and comprehend the risks and benefits associated with HRT. The patient agrees to promptly report any adverse side effects linked to the use of HRT to Warriors Weightloss and to discontinue usage until advised otherwise by Warriors Weightloss. The patient willingly assumes any potential risks associated with HRT.
The patient recognizes that representatives of Warriors Weightloss and/or Licensed Physicians Assistants are available for inquiries and concerns during standard business hours throughout the duration of their treatment.
The patient agrees that HRT medications supplied by Warriors Weightloss are for personal use exclusively and for no other purpose. The patient commits not to share, sell, or trade these medications and to ensure their safekeeping, taking responsibility for preventing loss or theft.
The patient acknowledges that they have the option to purchase medications from the pharmacy designated by Warriors Weightloss, and that said pharmacy will directly deliver the medications. The patient understands that they retain the right to procure medications from a pharmacy of their choice. Should they opt for a different pharmacy, the patient agrees to notify Warriors Weightloss in writing, specifying the chosen pharmacy.
The patient comprehends and agrees that federal regulations prohibit the return of prescribed medications.
The patient acknowledges that HRT treatment and medications are not covered by health insurance. Consequently, the patient agrees that all services and medications provided by Warriors Weightloss or its affiliated providers are to be pre-paid, and they will not seek reimbursement through their health insurance company, Medicare, Medicaid, or any other third-party payer.
The patient agrees that the patient-physician relationship established with Warriors Weightloss is not intended to replace the existing patient-physician relationship with their current primary care provider (PCP). The treatment offered by Warriors Weightloss will be administered in conjunction with the care provided by their current PCP.
The patient concurs that Warriors Weightloss exclusively treats patients aged 30 or older who exhibit documented symptoms of hormone deficiencies, namely Hypogonadism and Adult Growth Hormone Deficiency. No prescription will be dispensed unless a clinical necessity is determined based on mandatory lab work, physician consultation, and an evaluation of the patient's current health history, conducted either by their personal physician or an Warriors Weightloss -affiliated physician. The agreement to undergo lab work does not automatically qualify the patient for clinical necessity or the prescription of HRT.

This agreement, entered into between the party referred to as 'the patient' and Warriors Weightloss, hereby establishes the terms and conditions governing the utilization of hormone replacement therapy (HRT) involving DEA-controlled or scheduled medications. Both Warriors Weightloss and the patient mutually acknowledge that these stipulations and conditions are integral elements for maintaining a productive patient-practitioner rapport. It is crucial to recognize that adverse side effects and the potential development of physical or psychological dependence may arise following the utilization of these medications. Consequently, they are prescribed with utmost care.
This agreement between the patient and Warriors Weightloss  establishes the guidelines and conditions necessary for the utilization of hormone replacement therapy (HRT) involving DEA "controlled" or "scheduled" medications. Both Warriors Weightloss  and the patient mutually acknowledge the significance of these guidelines and conditions in sustaining a successful patient/physician relationship. It is imperative to recognize that adverse side effects and potential physical or psychological dependencies may emerge following repeated use of these medications; thus, these agents are prescribed with due diligence.
The patient accepts and consents to the following terms:
I acknowledge that the medical treatment provided by Warriors Weightloss  and its physician(s) is not accompanied by any claims, guarantees, promises, or warranties.
I understand that the medications I have procured are prescribed for my use based on diagnoses derived from my submitted medical history, blood/lab work, and physical examination. They are intended exclusively for the treatment of these specific diagnoses.
I commit not to engage in any illegal attempts to obtain "scheduled" hormone replacement therapy medications, nor will I seek them from any other healthcare practitioner without disclosing my current medication usage, recognizing that such actions are against the law.
I undertake to promptly report any adverse side effects arising from the use of my medications to Warriors Weightloss  and to discontinue their usage until I receive advice from Warriors Weightloss  to resume.
I am aware that the  Physician (MD) and/or Licensed Nurse Practitioner are available for inquiries and concerns during standard business hours throughout the course of my treatment.
I will take measures to safeguard my medications from potential loss or theft and assume responsibility for their secure storage.
I agree that these medications are intended solely for my personal use and no other purpose, and I will refrain from sharing, selling, or trading them.
I acknowledge the importance of using my medications at the prescribed rate and dosage, keeping them in their respective labeled containers.
I understand and accept that federal regulations prohibit the return of prescribed medications.
I commit to contacting Warriors Weightloss   4-6 weeks into the commencement of my therapy, and subsequently every 6 months, to coordinate follow-up blood testing and/or an office visit/consultation as stipulated by Warriors Weightloss .
I acknowledge that the patient/physician relationship established with Warriors Weightloss  is not intended to replace my existing patient/physician relationship with my current primary care provider (PCP). The treatment provided by Warriors Weightloss  will be conducted in conjunction with the care provided by my current PCP."

As required by the HIPAA Privacy Regulations, Warrior Weightloss . May not use or disclose your protected health information without your authorization.

1.I hereby authorize Warrior Weightloss or any of its employees to use or disclose my Patient Health Information to the following person(s), entity(ies), or business associated with this office (List laboratories, physicians that will receive information)
2.Patient Health information authorized to be disclosed:
Lab Work, medical history, physician examinations, diagnoses on therapies, telemedicine encounters and tele-health encounters
3.For the specific purpose of:
Bio-identical hormone therapy, Andropause Treatment, Menopause Treatment and Hormone Deficiency Treatment7
4.I understand that the information disclosed above may be re-disclosed to additional parties and no longer protected for reasons beyond our control.
5.Unless otherwise revoked, this Authorization will expire on:
6.I understand that I have the right to:

     1.Revoke this authorization by sending written notice to Warrior Weightloss and that revocation will not apply to information that has already been released in response to this authorization.
     2.lnspect a copy of Patient Health information being used or disclosed under federal law.
     3.Refuse to sign this authorization.
     4.Receive a copy of this authorization.
     5.Restrict what is disclosed with this authorization.
7..understand that my refusal to sign this document will not affect my treatment, payment, enrollment in a health plan, or eligibility for benefits merely because I do not provide authorization to use or disclose protected patient health information.
8.By signing below, I understand and acknowledge that:

     1. I have read and understand this Authorization
     2. If I have any questions about disclosure of my protected information, I may contact my patient manager at Warrior Weightloss - 561-826-4251

Thank you for your interest in Warriors Weightloss . A company that provides Hormone Replacement Therapy (?HRT?) and Medical Weight loss. Individuals seek our medical treatments to replace hormones or to lose weight to improve overall health and wellbeing.

Before we can provide HRT or Medical Weight Loss, Warriors Weightloss  requires the following:

Acceptable results of laboratory tests. (HRT ONLY)
Verification of access to primary care physician with whom you have had recent (within the preceding 12 months) physical examination (copy of the physical examination is required). (HRT ONLY)
An office visit to Get Express Test affiliated physician and / or telemedicine counter with a Warriors Weightloss  affiliated physician.
Completion of all Warriors Weightloss  paperwork.
Often individuals who are referred to us have previously received or are currently using medication from other physicians or HRT companies who may or may not follow the same medical evaluation or treatment protocols as we do. In some cases, where inappropriate medications, dosage levels or protocols were provided, an individual's Medical Directors, affiliated physicians and physician extenders take no responsibility and assume no liability for an individual's participation in any prior HRT program. Warriors Weightloss  does not use or condone the use of performance enhancement protocols or cyclical hormone therapies.

By signing this waiver you are holding Warriors Weightloss . (its employees, physicians, agents and associates) harmless for any damages and liability including without limitation, attorneys fees and costs at all levels of trial and appeal related to health issues that are present or may arise in the future from previous (whether disclosed or undisclosed to Warriors Weightloss ) HRT therapies or Medical Weight loss medications or protocols.

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