Please list current symptoms & concerns prompting your visit
Personal & Family History
FEMALE HORMONE HISTORY
HORMONE REPLACEMENT THERAPY QUESTIONNAIRE:
Telltale Symptoms of Hormonal Imbalance in Women (HIMB)
This basic questionnaire can be very useful for women to describe the kind and severity of their low estrogen symptoms.
HORMONE REPLACEMENT THERAPY QUESTIONNAIRE:
ADAM questionnaire about symptoms of low testosterone
(Androgen Deficiency in the Aging Male)
The basic questioner can be very useful for men to describe the kind and severity of their low testosterone one symptoms.
- If you Answer Yes to number 1 or 7 or if you answer Yes to more than 3 questions, you may have low Testosterone.
SCORE USING THE FOLLOWING· 0--NEVER 1--SOMETIMES 2-- REGULARLY 3--OFTEN 4--CONSTANTLY
SCORE EACH FROM 0 -10, WITH 10 BEING HIGHEST:
Integrative Chiropractic Symptom Analysis
In an effort to provide you with complete and overall wellness care, we would like to invite you to share the following information so that Dr. Russell can assist you with any additional symptoms or conditions you might be facing.
HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING SYMPTOMS/CONDITIONS IN THE PAST 6 MONTHS (CHECK ALL THAT APPLY TO YOU)
BLOOD PANEL SERVICE
Thank you for choosing the services of Vital Force Anti-Aging (VFAA). An important part of our service is to make sure the costs of patient care are as minimal and affordable as possible.
- VFAA require payment at the time of service.
The Lab’ VFAA use will be happy to work with your insurance company to the full benefits of your cover and bill them for the full reimbursement of your treatment.
Should your health insurer decline to cover this service we will require payment of up to $250. Please insert below your preferred payment details below:
Date Format: MM slash DD slash YYYY
MEDICAL CONSENT AGREEMENT:
- This agreement between ("Patient'') and Revive IV Hydration lounge (Rll establishes guidelines and conditions for the use of IV Vitamin and Hydration Therapy. RL 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 repeated use of these medications and, therefore. these agents are prescribed with caution. The patient agrees and accepts to the following conditions:
- I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions In accordance with applicable state and Federal law.
- I certify that the answers I provided to the health questions on the Health History 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.
- I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
- I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effect related to my treatment to Revive IV Hydration Lounge and discontinue use until advised to resume usage by my health care
provider.
- I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
- I understand that representatives of Revive IV Hydration Lounge and/or Licensed Physicians Assistant are available 'for questions and/or. concerning during normal business hours throughout the course of my treatment.
- I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by Revive IV Hydration Lounge 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.
- I agree that the Revive IV hydration Lounge/physician relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by Revive IV Hydration Lounge will be in conjunction with the care provided by my current PCP.
- I agree that I will use my medication at the prescribed rate and dosage and will keep the medication In its respective labeled container.
- I have read and agree to the terms of this the Therapy Management Agreement.
- I consent to text message appointment reminders. (Data rates may apply)
HRT AGREEMENT
- This agreement between ("Patient") and Revive IV Hydration lounge establishes guidelines and conditions for the use of hormone replacement therapy ("HRT") involving DEA "controlled" or "scheduled" medications. PP 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 repeated use of these medications and, therefore, these agents are prescribed with caution. The patient agrees and accepts to the following conditions:
- 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 law.
- I understand and agree that no medical treatment or medication provided to me by Revive will be used for the purposes of bodybuilding, performance enhancement or physical appearance.
- I certify that the answers I provided to the health questions on the Health History 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.
- 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.
- I have discussed and understand the risks and benefits associated with HRT. I will immediately report any adverse side effect related to the use of my HRT to Revive Therapy and Wellness and discontinue use until advised to resume usage by Progressive Health Institute. I voluntarily assume any and all possible risks which may be associated with HRT.
- I understand that representatives of Revive Therapy and Wellness and/or licensed Physicians Assistant are available for questions and/or concerning during normal business hours throughout the course of my treatment.
- I agree that the HRT medications furnished by Revive Therapy and Wellness are for my personal use only and for no other purpose. I will not share, sell. or trade my medications. I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
- I will be able to purchase the medications from the pharmacy designated by Revive Therapy and Wellness and the pharmacy will send medication directly to me. I understand I have the right to purchase my medications from any pharmacy of my choice.
- If I chose to obtain medications from a pharmacy of my own choice, I must notify Revive Therapy and Wellness in writing of my intention to do so and include the name of the pharmacy in my request.
- I agree and understand that federal regulations prohibit the return of prescribed medications.
- I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by Revive Therapy and Wellness 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.
- I agree that the Revive Therapy and Wellness 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 Revive Therapy and Wellness will be in conjunction with the care provided by my current PCP.
- I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.
- I understand that Revive Therapy and Wellness only treats patients over the age of 30 with documented symptoms of hormone deficiencies (Hypogonadism and Adult Growth Hormone Deficiency). No prescription will be provided unless a clinical need exists based on required lab work, physician consultation, and current health history through either patient's personal physician or a Progressive Health Institute - affiliated physician. Agreeing to lab work does not automatically qualify patient to clinically necessity and prescription of HRT.
- I understand that should I choose to opt out of therapy with Vital Force Anti-Aging, all of my prescriptions will be cancelled through the pharmacy and will not be transferred to any other pharmacy.
- This Therapy Management Agreement is a binding contract for a minimum of 3 consecutive months. If you choose to cancel your membership prior to the 3 month commitment you will be responsible for the payment of the remainder of your 3 month commitment. (IE: Used HRT 1 month, then cancel - responsible for 2 remaining months).
- I consent to text message appointment reminders. (Data rates may apply)
I have read and fully understand clause #1 through #15 on this agreement and by signing below I agree that Revive Therapy and Wellness has permission to charge my account, should I choose to opt out of the Hormone Replacement Therapy Program, I acknowledge my card will be charged the full three month amount accordingly. Please sign above with mouse or finger (if tablet)
Date Format: MM slash DD slash YYYY
Here at Revive, we like to stay in touch with our current and potential patients via e-mail, text messages, and social media. We would love to have you involved but understand the hesitation. Please read and mark the options below if you are uninterested in these marketing approaches.
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