The undersigned Patient ("Patient") authorizes and instructs Elite HRT ("Elite HRT") 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 Elite HRT ("Physicians")
could result in inappropriate treatment. Patient authorizes Elite HRT 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 Elite HRT, 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 Elite HRT under this
Agreement. Patient agrees to present photo identification upon receiving any blood testing pursuant to a
Elite HRT or Physician test requisition. Patient acknowledges that medications, laboratory and diagnostic
testing and medical services supplied or obtained by Elite HRT, are not covered or reimbursed by Medicare,
Medicaid or any other insurance.
Patient specifically swears and acknowledges that he or she is not a professional or amateur
athlete/bodybuilder. Patient specifically swears and acknowledges that he or she is not seeking treatment
or prescription medication by Elite HRT and/or Physician for the purpose of athletic performance or
cosmetic enhancement. It is outside the scope of Elite HRT and the Physician to provide these services or
prescriptions under those circumstances. Elite HRT and the Physician only provide treatment and
prescription medication to patients who have a deficiency and medical need as established by laboratory
blood tests, physical examination, this MHF and in the sole determination of the Physician.
Patient acknowledges that Elite HRT's employees and advisors are not licensed physicians and that Physicians
obtained on my behalf by Elite HRT are independent contractors, compensated by Patient with funds provided
to Elite HRT. I further understand and agree that Elite HRT and Physicians are rendering the medical care,
services and treatment, and that Elite HRT 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 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 Elite HRT and
Physician with written notice of any such adverse reaction or side effect. I further acknowledge and agree
that Elite HRT 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 Elite HRT 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 hormone blood level objective sought as a result of Patient's hormone replacement therapy, as
prescribed by Physician, may be the highest level of standard reference range for Patient's age and sex,
or, in some cases, above such range, to the level of a younger person, and that such range 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 replacement treatment. Patient acknowledges that
recombinant human growth hormone replacement 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 replacement therapy for the purpose of authorizing
Physician to administer such treatment to relieve body ailments and deficiencies. Patient further
acknowledges that the methods of medical treatment offered by Elite HRT 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 has contacted Elite HRT for a specific prescription medication to treat an already identified
medical 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.
Patient represents that he or she is under the care of a primary care physician and the Physician, 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 qualifying for any treatment or any medication prescribed by Physician,
Patient agrees to have a comprehensive physical examination and to submit same to become a part of
patient's records to be maintained by Elite HRT. Patient agrees to notify his or her primary care physician
and advise such physician that Patient is undergoing hormone replacement 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 agrees to indemnify, defend, protect and hold harmless Elite HRT 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, Elite
HRT 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 Elite HRT or Physician, harm or injury resulting from medical care or
pharmaceuticals provided directly or indirectly by Elite HRT 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.
