Fadeaway Medical Waivers Step 1 of 10 - Patient Information 0% PERSONAL INFORMATIONName(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Address (Street)(Required) City(Required) State(Required) Zip Code(Required) Telephone Number (Mobile)(Required)Telephone Number (Home)Telephone Number (Work)Email(Required) ID or Driver's License #Laws and regulations require patients receiving Controlled Substances, to provide their ID or Driver's License Number. ConsentI do not wish to share my phone number(s) and or email address with Fadeaway Medical Esthetics for the purposes of marketing through text messages, phone calls, or emails of products and services offered by Prime Medical Group and or it's affiliates or assigns. I don't want to shareEmergency Contact Name Relationship Phone Number Primary Care Physician Date of Last Labs MM slash DD slash YYYY Date of Last Physical MM slash DD slash YYYY How did you hear about us?(Required)How did you hear about us? Google / Search Engine Social Media Friends / Family Edison Park Fest Referral Name What brings you to Fadeaway Medical? What are your main concerns or questions you would like to have answered by a healthcare provider at Fadeaway Medical? MEDICAL HISTORYIn the past 48 hours, have you or anyone you have been in close contact with, been diagnosed with COVID-19 or placed in quarantine for possible exposure to COVID-19?(Required) Do you have a fever ( temperature Have you experienced any over 100.4◦ F or 38◦ C) without gastrointestional symptoms such as having taken any fever-reducing nausea, vomiting, diarrhea, or loss medications? of appetite?(Required) Have you been asked to self-isolate or quarantine by a medical professional or a local public health official?(Required) Do you have a personal history with any of the following?Do you have a personal history with any of the following? Breast Cancer Uterine Cancer Ovarian Cancer Prostate Cancer Thromboembolic Event (Blood Clot) Thromboembolic Disorder Coronary Heart Disease Myocardial Infarction (Heart Attack) Medical ConditionsPlease list any other medical conditions you've been diagnosed with. Add RemoveAllergy Information - Are you allergic to any medications?Are you allergic to any medications? Yes No Don't Know If yes, please indicate which one(s) and your reaction(s):If yes, please indicate which one(s) and your reaction(s): Do you have any other allergies?Do you have any other allergies? Yes No Don't Know Medication HistoryPlease indicate the medications, vitamins and supplements you are currently taking. Include both prescription and over-the-counter. Medication/Vitamin/SupplementDoseFrequencyDate StartedPrescriber Add RemoveIf yes, please indicate which one(s) and your reaction(s):If yes, please indicate which one(s) and your reaction(s): Surgical HistoryPlease list date, location and type of surgery/surgeries previously had. DateLocationType Add RemoveHospitalization HistoryPlease list date, location and reason for previous hospitalization(s).DateLocationReason Add Remove SOCIAL HISTORYMarital StatusMarital Status Single In a Relationship Engaged Partnered Married Seperated Divorced Widowed Employment StatusEmployment Status Unemployed Employed Retired Disabled Living SituationLiving Situation Alone With spouse/significant other With family With child/children With friend(s)/roomate(s) Diet / Nutrition - How many meals do you consume a day?How many meals do you consume a day?Please enter a number from 0 to 10.How would you describe your diet?How would you describe your diet? Low carb Low fat High protein Vegetarian Vegan Exercise - How often do you exercise?How often do you exercise? Almost Daily At least 3x/week Occasionally Rarely Never Exercise - If you exercise, what do you do? For how long? How often?If you exercise, what do you do? For how long? How often? Caffeine - Do you consume drinks with caffeine?Do you consume drinks with caffeine? Yes No If yes, what type of caffeine?If yes, what type? Coffee Tea Soda Energy drinks Pre-workout Other If yes, how many and how often do you drink caffeine?If yes, how many and how often? Sleep Habits - How many hours do you sleep on average per night?How many hours do you sleep on average per night?Please enter a number from 0 to 24.Do you have difficulty falling asleep?Do you have difficulty falling asleep? Yes No Do you have difficulty staying asleep?Do you have difficulty staying asleep? Yes No Do you or have you taken any sleep aids?Do you or have you taken any sleep aids? Yes No Alcohol - Do you drink alcohol?Do you drink alcohol? Yes No If yes, what type of alcohol?If yes, what type? Beer Wine Vodka Whiskey Tequila Other If yes, how many and how often do you drink?If yes, how many and how often? Tobacco - Do you smoke cigarettes?Do you smoke cigarettes? Yes No If yes, how many per day do you smoke?If yes, how many per day?Please enter a number from 0 to 50.If yes, when did you start smoking?If yes, when did you start? MM slash DD slash YYYY If you don't smoke cigarettes, have you ever smoked?If you don't smoke cigarettes, have you ever smoked? Yes No If yes, when did you start smoking?If yes, when did you start? MM slash DD slash YYYY How many per day do you smoke?How many per day did you smoke?Please enter a number from 0 to 50.When did you stop smoking?When did you stop? MM slash DD slash YYYY Do you use any other type of tobacco?Do you use any other type of tobacco? Yes No If yes, what? How much and often?If yes, what? How much and often? Illicit Drugs - Do you use illicit drugs?Do you use illicit drugs? Yes No If yes, what type and how often?If yes, what type and how often? Sexual History - Are you currently sexually active?Are you currently sexually active? Yes No If yes, are you currently having sex with:If yes, are you currently having sex with: A woman (or women) A man (or men) Both men and women Are you in a committed, mutually monogamous relationship?Are you in a committed, mutually monogamous relationship? Yes No Are you trying to get pregnant?Are you trying to get pregnant? Yes No If not, do you practice safe sex?If not, do you practice safe sex? Yes No If yes, list contraceptive / barrier method:If yes, list contraceptive / barrier method: Questionnaire - Select all that apply.Select all that apply. Decline in your feeling of general well-being Difficulty concentrating Memory problems Physical exhaustion/Lacking vitality (General decrease in performance, reduced activity, lacking interest in leisure activities, feeling of getting less done, of achieving less, having to force oneself to undertake activities) Low energy, often feeling tired and fatigued Increased need for sleep Sleep problems (Difficulty in falling and or staying asleep) Weight gain Difficulty losing weight Decrease in muscular strength (Feeling of physical weakness) Joint pains and/or muscle aches Depressed mood (Feeling down, sad, on the verge of tears, lack of drive/motivation) Anxiety (Feeling panicky) Nervousness (Inner tension, restlessness, feeling fidgety) Irritability (Feeling aggressive, easily upset by little things, moody) Mood swings Emotional Females Only(Males go to next page)Gynecologic History - How would you describe your current menstrual status?How would you describe your current menstrual status? Premenopause (Before menopause; Having regular periods) Perimenopause (Changes in periods, but have not gone 12 consecutive months without a period) Postmenopausal (After menopause) Age at first menstrual period:Age at first menstrual period:Please enter a number from 0 to 90.Approximate date of your last menstrual period:Approximate date of your last menstrual period: MM slash DD slash YYYY Are your periods usually regular?Are your periods usually regular? Yes No How often do they usually occur? Every____ DaysHow often do they usually occur? Every____ DaysHow many days does your period usually last?How many days does your period usually last?If you no longer having periods, at what age did you have your last period?If you no longer having periods, at what age did you have your last period?Was your menopause:Was your menopause: Spontaneous (“Natural”) Surgical (Removal of both ovaries) Other Do you have a cervix?Do you have a cervix? Yes No Don't know Do you have a uterus?Do you have a uterus? Yes No Don't know Do you have both ovaries?Do you have both ovaries? Yes No Don't know When was your last pap smear?When was your last pap smear? MM slash DD slash YYYY History of abnormal results?History of abnormal results? Yes No Don't Know When was your last mammogram?When was your last mammogram? MM slash DD slash YYYY History of abnormal results?History of abnormal results? Yes No Don't Know Obstetric History - Please indicate method of birth control:Please indicate method of birth control: None Sterilization / Tubal Ligation Birth control pill/ring/patch IUD Injectable hormone Implanted hormone Diaphragm Foam/Gel Condoms How many times have you been pregnant?How many times have you been pregnant?How many living children do you have?How many living children do you have?How many were adopted?How many were adopted?Please provide number of full term birthsFull term birthsPlease provide number of premature birthsPremature birthsPlease provide number of miscarriagesMiscarriagesPlease provide number of abortionsAbortionsAny complications during pregnancy, delivery, or postpartum?Any complications during pregnancy, delivery, or postpartum? Yes No If yes, please describe:If yes, please describe: QuestionnaireSelect all that apply. Hot flashes Night sweats Irregular periods Shorter cycles Longer cycles Lighter periods Heavier periods Spotting or bleeding between periods Painful periods Abnormal vaginal bleeding after menopause PMS (including but not limited to mood swings, bloating, cramping, breast tenderness, and/or headaches prior to period) Decrease in sexual interest/ desire/ libido (lacking pleasure in sex, lacking desire for sexual intercourse) Loss of sexual response (weaker or absent orgasm) Vaginal dryness Pain during intercourse More frequent urinary tract/bladder infections Incontinence Frequent urination Excessive urination Vaginal itching Abnormal vaginal discharge Increased vaginal infections Males Only(Females go to next page)When was your last PSA level tested?When was your last PSA level tested? MM slash DD slash YYYY Any elevated results?Any elevated results? Yes No If yes, when?If yes, when? MM slash DD slash YYYY When was your last prostate exam?When was your last prostate exam? MM slash DD slash YYYY Any abnormal findings?Any abnormal findings? Yes No If yes, when?If yes, when? MM slash DD slash YYYY QuestionnaireSelect all that apply. Frequent urination throughout the night Decreased force of urination Feeling of incomplete emptying of bladder after urination More frequent urinary tract/bladder infections Decrease in sexual interest / desire / libido (lacking pleasure in sex, lacking desire for sexual intercourse? Feeling that you have passed your peak sexually Decrease in ability and / or frequency to perform sexually Decrease in the number of morning erections Difficulty obtaining / maintaining an erection Loss of sexual response / ejaculation (weaker or absent orgasm) Family History(Male and Female)Do you have a family history of any of the following?Do you have a family history of any of the following? Breast Cancer Uterine Cancer Prostate Cancer MotherMother MaternalMaternal FatherFather PaternalPaternal Sibling(s)Sibling(s) Sister Brother Maternal / Paternal Sibling(s)Maternal / Paternal Sibling(s) Sister Brother OtherOther THERAPY MANAGEMENT AGREEMENTConsent(Required)This agreement between (“patient “) and Fadeaway Medical Esthetics establishes guidelines and conditions required for the use of hormone replacement therapy (“HRT”) involving DEA “controlled” or “scheduled” medications. Fadeaway Medical Esthetics 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 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 a 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 Fadeaway Medical Esthetics will be used for the purpose of bodybuilding, performance enhancement or physical appearance. 3. I certify that the answers I provide to the health questions on the Health History form and otherwise to Fadeaway Medical Esthetics affiliated physicians’ or 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 health care practitioner without disclosing my current medical usage of 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 and adverse side effects related to the use of my HRT to Fadeaway Medical Esthetics and discontinue use until advised to resume usage by Fadeaway Medical Esthetics. I voluntarily assume any and all possible risks which may be associated with HRT. 6. I understand that representatives of Fadeaway Medical Esthetics and / or Licensed Medical Professionals are available for questions and / or concerning during normal business hours throughout the course of my treatment. 7. I agree that HRT medications furnished by Fadeaway Medical Esthetics are for my personal use only and for no other purpose. I will not share, sell or trade 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 Fadeaway Medical Esthetics and the pharmacy will send medications directly to me. I understand I have the right to purchase my medications from any pharmacy of my choice. If I choose to obtain medications from a pharmacy of my own choice, I must notify Fadeaway Medical Esthetics in writing of my intention to do so and include the name of the pharmacy in my request. 9. I agree and understand that federal regulations prohibit the return of prescribed medications. 10. I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Fadeaway Medical Esthetics 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 Fadeaway Medical Esthetics 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 Prime Medical Group will be in conjunction with the care provided by my current PCP. 12. I agree that Fadeaway Medical Esthetics only treats patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism, testicular hypofunction and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consolation and current health history through either patient’s personal physician or a Fadeaway Medical Esthetics affiliated medical provider. Agreement to lab work does not automatically qualify patient to clinically necessity and prescription of HRT. I have read and agree to the terms of the Therapy Management Agreement..Patient SignatureName(Required) First Last Date:(Required)Date: MM slash DD slash YYYY MEDICATION MANAGEMENT AGREEMENTThis agreement between (Patient Name) and Prime Medical Group(Required)This agreement between (Patient Name) and Prime Medical Group First Last Medication Management Agreement(Required)This agreement between myself (patient) and Fadeaway Medical Esthetics. Establishes guidelines and conditions required for use of hormone replacement therapy (HRT) involving DEA “controlled” or “scheduled” medications. Fadeaway Medical Esthetics., and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient / physician relationship. Adverse side effects and / or physical / psychological dependencies may develop after repeated use of these medications and therefore, these agents are prescribed with caution. The patient accepts and agrees to the following conditions: 1. I understand that the medical treatment offered by Fadeaway Medical Esthetics and their physician(s) is not accompanied by any claims, guaranteed, promises or warranties. 2. I understand that the medications I have purchased are prescribed for me based on diagnoses derived from my submitted medical history, blood / lab work, and physical examination. They are to be used exclusively for treatment of these diagnoses. 3. I will not attempt to obtain “scheduled” hormone replacement therapy medications illegally or from any other healthcare practitioner without disclosing my current medication usage. I understand that it’s against the law to do so. 4. I will immediately report adverse side effects to the use of my medications to Fadeaway Medical Esthetics and discontinue use until advised to resume usage by Fadeaway Medical Esthetics. 5. I understand that the Fadeaway Medical Esthetics Medical Provider and / or Licensed Medical Professionals are available for questions and / or concerns during normal business hours throughout the course of my treatment. 6. I will safeguard my medications from loss or theft and will be responsible for their safekeeping. 7. I agree that these medications are for my personal use only and no other purpose and I will not share, sell or trade my medications. 8. I agree that I will use my medications at the prescribed rate and dosage and will keep the medications in its respective labeled container. 9. I agree and understand that federal regulations prohibit the return of prescribed medications. 10. I agree that if I do any IM or SQ injections with a Fadeaway Medical Esthetics professional, I will not hold Fadeaway Medical Esthetics or any affiliate, independent contractor or employee liable for any reactions to medications. 11. I agree to contact Fadeaway Medical Esthetics 4-6 weeks into the start of my therapy (and every 6 months thereafter) to arrange for any follow-up blood testing and / or an office visit / consultation as required by the Fadeaway Medical Esthetics Medical Provider. 12. I agree and understand that my fees include a one hundred dollar appointment deposit which will be applied to the cost of my examination, blood work or therapy. To cancel an appointment, I must email my cancellation request to my patient care coordinator at least 48 hours prior to my scheduled appointment time or the $99 deposit will not be refunded. 13. I agree that the Fadeaway Medical Esthetics patient / physician relationship is not intended to replace the existing patient / physician relationship with my current primary care provider (PCP) and my Prime Medical Group treatment will be in conjunction with the care provided by my current PCP. I have read and agree to the Medication Management Agreement..Patient SignaturePatient Name(Required) First Last Date:(Required)Date: MM slash DD slash YYYY HEALTH INFORMATION AUTHORIZATIONPatient Name(Required) First Last Address:(Required)Address: Date of Birth:(Required)Date of Birth: MM slash DD slash YYYY Date of Request:(Required)Date of Request: MM slash DD slash YYYY Consent(Required)As required by the HIPAA Privacy Regulations, Fadeaway Medical Esthetics. May not use or disclose your protected health information without your authorization. 1. I hereby authorize Fadeaway Medical Esthetics 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 Treatment 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 one year from request date. 6. I understand that I have the right to: a) Revoke this authorization by sending written notice to Prime Medical Group. and that revocation will not apply to information that has already been released in response to this authorization. b) Inspect a copy of Patient Health information being used or disclosed under federal law. c) Refuse to sign this authorization. d) Receive a copy of this authorization. e) Restrict what is disclosed with this authorization. 7. I 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: a) I have read and understand this Authorization b) If I have any questions about disclosure of my protected information, I may contact my patient manager at Fadeaway Medical Esthetics. I have read and agree to the Health Information Authorization.Patient SignaturePatient Name(Required) First Last Date:(Required)Date: MM slash DD slash YYYY WAIVERConsent(Required)Thank you for your interest in Fadeaway Medical Esthetics. A company that provides Hormone Replacement Therapy (“HRT”). Individuals seek our medical treatments to replace hormones to improve overall health and well-being. Before we can provide HRT, Prime Medical Group requires the following: A. Acceptable results of laboratory tests. B. 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). C. An office visit to Fadeaway Medical Esthetics affiliated physician and / or telemedicine counter with a Fadeaway Medical Esthetics affiliated physician. D. Completion of all Fadeaway Medical Esthetics. 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. Fadeaway Medical Esthetics. Does not use or condone the use of performance enhancement protocols or cyclical hormone therapies. By signing this waiver you are holding Fadeaway Medical Esthetics. (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 Fadeaway Medical Esthetics) HRT therapies, medication or protocols. I certify that I have not previously received HRT and that I am not currently undergoing and / or receiving HRT. I have read and agree to the statements, waivers and disclosures in this document.Patient SignaturePatient Name(Required) First Last Date:(Required)Date: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.