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Please complete the Medical History Form below. Please be completely accurate with your answers. Your information will be stored on our secure server. One of our physicians or clinical advisers will contact you as soon as possible.

*Required Fields

SECTION 1: Personal information

*Name: (First/M.I./Last):

ADDRESS

*Address 1:
Address 2:
*City:
*State:
*Zip:
*Country:

PHONE NUMBERS

Home:
Best time to call:
Work:
Best time to call:
Cell:
Best time to call:

OTHER

*Occupation:
Have you already contacted Kingsberg Medical? If so, please provide the name of your clinical adviser:

SECTION 2: Medical history

GENERAL

*Date of birth:
*Gender:

 

*Weight:
*Height:

PRIMARY PHYSICIAN INFORMATION

Physicians Name:
Phone:
Date of last physical exam with above physician?:

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:
Cardiovascular disease:
Diabetes, thyroid or other Endocrine Disorder:
Hypertension:
Lipid Disorder:
Prostate cancer:
Other forms of cancer:
Other illnesses:
Explain family health history:

LIFESTYLE INFORMATION

Do you smoke?
If Yes, how much do you smoke per day?
Do you drink alcohol?
If Yes, how much do you drink per week?
Do you take over the counter supplements?
If Yes, list Name and Quantity per day/week.
Do you exercise regularly?
If Yes, please describe.
Have you tried to lose weight before?
If Yes, please describe.

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:
Any known deficiency including minerals and electrolytes:
Use of medications (if yes, list medications below):
Blood disorders:
Immune disorders:
Cancer:
Chemical Dependency:
Carpal Tunnel syndrome:
Lung disorder:
Orthopedic or muscle disorder including fracture or joint disorders:
Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack:
Allergies to Medications:
Upper respiratory:
Edema / excess fluid retention:
Poor wound healing:
Emotional disorders / depression:
Renal disease:
Genital - Urinary disorder:
Hyperlipidemia:
Hypertension:
Neurological disorders:
Thyroid, Diabetes or other endocrine disorder including insulin resistance:
Arthritis:
Bursitis:
Rheumatism:
Sports Injury(s):
Other illnesses:
Explain the history of any above checked diseases:
*List all the medications you are taking.
Please be specific (Name, dosage, etc.) or specify "none":

STEROIDS

Prior history of Steroids or hormones?
If yes, please select:
Male
Test:
Deca:
Winstrol:
hGH:
Thyroid:
Other:
Type/Dose/Frequency:
Last used:
Prior Medical Records / Labs?
Any side affects?
Used estrogen-blocker?

QUESTIONS FOR TREATMENT

Do you currently have or ever had any of the following symptoms? As Kingsberg Medical specializes in hormone replacement therapy, it is important to take a complete history of any physical symptoms which might be related to your hormonal status.
If Yes, please check and explain below:
Increased lack of drive:
Increasing fat deposits about abdomen and/or thighs:
Increasing mood swings:
Increasing sagging muscles or breasts:
Increasing wrinkles:
Increasingly stressed:
Decreased desire and ability to exercise:
Decreased energy or endurance:
Decreased sense of well-being:
Decreasing memory:
Decreasing muscle strength:
Progressive osteoporosis, decreasing bone mass or stooped posture:
Cold or heat intolerance:
Currently Pregnant:
Depression:
Difficulty sleeping:
Headaches / Migraines:
Hot flashes:
Loss of concentration, sociability, activity:
Loss of interest in sex:
Muscle loss:
Sagging, loose or thin skin:
Sore Muscles, join pain(s) or swelling:
Thinning or loss of hair:
Urogenital atrophy:
Weight loss - Unexplained:
Other:
Please use this space to explain any additional information:

SECTION 3: Signature

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 acknowledges that therapies and laboratory and diagnostic testing services obtained by Kingsberg Medical, and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.

Patient acknowledges that Kingsberg Medical's employees and 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 treatment being prescribed by Physician may or may not cause the effect being sought, and that such treatment 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 treatment. Patient acknowledges that human chorionic gonadotropin 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 therapy for the purpose of authorizing Physician to administer such treatment to attempt to enhance Patient's physical condition and health. 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 solicits Kingsberg Medical for a specific prescription medication to treat an already-identified 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, where Physician is licensed to practice medicine.

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 taking any medication prescribed by Physician, Patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that Patient is undergoing hormone 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 Palm Beach 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 or damages from the Indemnified Parties herein.

*Yes, I agree to the terms and conditions disclosed herein.:
*Digital Signature Please Print Name:

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