CONSENT FOR MEDICAL TREATMENT
By submitting payment this invoice, I authorize and give my consent for the evaluation and treatment by The Medical Institute of Anti-Aging for the administration of hormones, other pharmaceutical interventional therapies and dietary supplements. The goal and possible benefits of this therapy are to prevent, reduce or control the dysfunction associated with imbalances of the body, through hormonal balancing, control of oxidative stress, and other clinically significant therapeutic agents.
I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medical community as new, controversial, and unnecessary by the Food and Drug Administration, given the present state of knowledge regarding the human aging process.
I understand and am fully satisfied with the knowledge, that there are risks (both known and unknown) to any medical procedure, treatment and therapy, including the proposed treatment for slowing the ageing process, and that it is not possible to guarantee or give assurance of a successful result. I freely acknowledge and accept these known and unknown general risks.
I appreciate, understand, and agree to follow the proposed treatment and therapy as prescribed without any deviation, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the hormone(s) or other designated therapies that may be prescribed to me possibly more than once daily, and consent to periodically have my blood drawn, saliva, or urine specimens obtained for laboratory monitoring and analysis.
I also agree to take the dietary supplements, hormones preparations, and other designated therapies (exercise, nutritional recommendations, lifestyle improvements, stress-response management) on the schedule that has been individually worked out for me, as specifically prescribed in detail. I have completely and faithfully disclosed my complete medical history, all prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other over-the-counter medications, recreational drugs or social substances, herbs extracts, and other dietary supplements to you.
I will now certify that I am under the care of another physician(s) for all other medical conditions, excluding physicians and practitioners of The Medical Institute of Anti-Aging. I will consult this physician(s), excluding physicians and practitioners of The Medical Institute of Anti-Aging, for any and all other medical services that I require, including those classified as an emergency or non-emergency personal health crisis. I will also refer my care to the other physician(s) as it relates to his/her specialty, e.g., general recommended screening from the American Cancer Society or the American Heart Association, and for emergent or preventative screening techniques.
I understand and accept that if at any time I am not satisfied with services or rendered by The Medical Institute of Anti-Aging, I may cancel my membership at any time. I understand and accept that if at any time I do not agree with these terms and conditions, I may cancel my membership at any time. I understand that the card on file will automatically be charged on a monthly basis and thus, I am automatically renewing my consent for treatments. Refunds are at the discretion of The Medical Institute of Anti-Aging. I understand that the The Medical Institute of Anti-Aging reserves the right to terminate my subscription at any time.