The undersigned Patient (“Patient”) authorizes and instructs National TRT Clinics and its agents (“NTRTClinics”) 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 has completed with this Agreement an accurate medical history form (MHF). Patient agrees that the MHF was completed truthfully and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to the medical practitioners referred by National TRT Clinics could result in inappropriate treatment and harm. Patient authorizes National TRT Clinics 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 National TRT Clinics, agents, 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 National TRT Clinics under this Agreement. Patient agrees to present photo ID upon receiving any blood testing pursuant to “NTRTClinics” or agents test requisition.
Patient understands that NTRTClinics does not cooperate with insurance companies and any services provided will be paid by the patient directly. Insurance will not be billed by NTRTClinics. NTRT Clinics and specifically the treating provider for said patient will determine soley if treatment is warranted. This determination will be based upon laboratory results, medical history, physical exam information, and consultation with patient either over phone and/or video chat or in person in clinic if applicable.
Patient agrees to comply with the medication instructions and will not deviate from prescribed regimen unless instructed by treating provider. If patient believes they are experiencing an adverse reaction or side effect arising from prescribed treatment they will immediately stop medication and contact NTRTClinics for further advice. In event of emergency such as shortness of breath, chest pain, loss of movement or feeling, patient will contact 911 or go to nearest emergency room.
I further acknowledge and agree that NTRTClinics is not liable for any negligent act or omission of the treating provider. Patient acknowledges that diagnosis and treatment may involve risk of injury, and that NTRTClinics and its agents have made no guarantees or warranties with regards to the diagnostic testing, analysis of test results, examination of medical history or treatment regimen.
Patient acknowledges that the hormone blood level goal sought as a result of treatment, 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. This includes no treatment at all and furthermore it has been explained that in many cases (not all) a hormone deficiency, such as testosterone, is not a medical emergency, and will not “directly” lead to death or significant harm. (Proper evaluation of each patient can help determine if a more serious cause of low testosterone is present that may lead to serious harm, death, or disease). The overwhelming evidence supports that low testosterone levels “indirectly” influence many metabolic parameters and may lead to increased risks for death and disease. Patient is consenting to treatment in order to alleviate symptoms of hormone deficiency.
Patient further acknowledges that the methods of medical treatment offered by NTRTClinics are not accompanied by guarantees or warranties. There will be no refund given for any medication. Patient is freely seeking medical consultation via the internet and acknowledges and consents to medical providers of NTRTClinics reviewing Patient’s medical history without the opportunity to conduct an in-person physical examination. Further, Patient agrees that Physician’s consultations, diagnosis, and treatments will be deemed to have occurred in Tennessee. Patient represents that he or she is under the care of a primary care doctor and the NTRTClinics provider, and he or she will not rely or substitute the advice of NTRTClinics provider 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 NTRTClinics. 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 Tennessee, 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 Williamson County, Tennessee 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. 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 NTRTClinics and its agents 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, NTRTClinics and/or agents 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 NTRTClinics or its medical providers, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by NTRTClinics and its medical providers. 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.
Liability Waiver and Hold Harmless: I voluntarily choose to undergo hormone replacement therapy. All potential risks and side effects have been fully explained to me. I acknowledge and understand those risks. I have assessed the risk on a personal basis, and my personal belief is the benefits of hormone therapy outweigh the risks (including concerns of TRT (testosterone replacement therapy) contributing to the growth of an undiagnosed prostate cancer). I understand that prostate cancer risk testing (PSA test), when deemed appropriate, will be done prior to start of any low testosterone treatment in order to assess risk. If patient is deemed high risk for prostate cancer TRT will be held (not started) and appropriate referral and/or consultation will be recommended. I hereby release and agree to hold harmless NTRTClinics, the entire Staff at NTRTClinics and the treating providers associated with my hormone replacement therapy. I have had adequate time to consider all options and research hormone replacement therapies. This agreement shall serve as release and hold harmless and is binding on behalf of myself, my heirs, assignees, designees, and personal representatives.
Initial boxes below to indicate your understanding
* I understand that NTRTClinics does not cooperate with any insurance companies. If any part of my prescription from NTRTClinics is sent to a local pharmacy, I agree to pay cash for that medication. I will not request that it be processed through my insurance.
* I agree that I will use my medications at the prescribed dosage and rate. In order to avoid confusion I will keep the medications in their appropriately labeled containers given by the pharmacy.
* I understand the medications I have purchased as part of my treatment regimen are prescribed only for me and based on a diagnosis derived from my overall clinical picture (medical history, lab results, physical examination, and tele-health consultation.
* I will immediately report any adverse side effects related to the use of my medication to NTRTClinics staff and discontinue use until advised to resume my medications by NTRTClinics.
* Lost or stolen medications will not be refilled nor will money be refunded. Frequent medication “issues” that may indicate diversion or irresponsible storage may result in my release from the care of NTRTClinics.
* I have reviewed the Terms and Conditions page and agree to the terms and conditions within. If I have questions or do not completely understand the terms and conditions I will contact National TRT Clinics for clarification before indicating my agreement with my initials.
sign name below
My signature indicates my understanding and agreement to the information above