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172 Center St Suite 8 Jackson, WY, 83001, USA
+1 (307) 203 8159
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I, the undersigned, wish to become a client of Prometheuz HRT (the "Company") and receive treatment from the Company's qualified healthcare professionals (referred to as the Professional Staff, comprising individuals in healthcare-related professions whose primary responsibilities include delivering healthcare services to clients, necessitating the use of medical judgment and discretion).
1. LIABILITY AND WAIVER OF LIABILITY
I acknowledge that I will be self-administering all over-the-counter medications and prescriptions recommended and prescribed by the Professional Staff. These may include various forms such as pills, injections, troches, patches, or nasal sprays. I understand that I will receive guidance on how to self-administer these medications and prescriptions. If I choose not to self-administer, I may visit the Company's facility for assistance, though additional fees may apply. I recognize that self-administration is done at my own risk, and neither the Company nor the Professional Staff shall be liable for any injuries or damages resulting from this, nor subject to any claims, demands, actions, causes of actions, or damages. I, along with my personal representatives, heirs, administrators, assigns, and successors, hereby release and forever discharge the Company, its successors, officers, agents, and employees from all such claims, demands, actions, causes of actions, or damages.
2. THERAPY
Before beginning any therapy offered by the Company, clients are required to undergo bloodwork. Upon receiving results, the Professional Staff will review them to create a personalized health optimization plan using recommended therapies. These therapies are based solely on the client's bloodwork, not personal opinions. It is important to note that these therapies are not guaranteed to be 100% effective, and the Company and Professional Staff are not liable for any side effects, outcomes, diseases, or even death potentially associated with these therapies.
3. FEES
Fees vary based on the lab package chosen and the medications prescribed by the Professional Staff. Prometheuz HRT offers several package options, details of which are available at https://dev.prometheuzhrt.com/. These packages include options tailored to different needs and budgets.
5. SUSPENSION/TERMINATION OF CLIENT/COMPANY RELATIONSHIP
Prometheuz HRT reserves the right to suspend or terminate my client relationship for reasons including non-payment of sessions, consultations, prescription orders, inappropriate behavior towards staff, non-compliance with treatment plans, or any other reason deemed sufficient at the Company's discretion.
6. CANCELLATION, REFUNDS
Prometheuz HRT maintains a strict no-refund policy. By purchasing services and/or products, I authorize the Professional Staff and/or Company to order products for my treatment, including prescriptions, in advance. I understand these products may have short shelf lives and require timed ordering. If I choose to cancel any purchased product(s), the Company may approve the cancellation, but I will remain responsible for the full cost of the already ordered product(s), and I understand that refunds are not provided in such cases.
7. ENTIRE AGREEMENT
This agreement represents the complete and exclusive understanding between Prometheuz HRT and me. Any promise, representation, understanding, oral or written, not included herein, is waived.
I, the undersigned, acknowledge and agree as follows:
When a medication or device is authorized for medical use by the Food and Drug Administration (FDA), its manufacturer provides a label detailing its intended use. Once approved, physicians may use these products "off-label" for other purposes, provided they are well-informed about the product, base its use on sound scientific methods and medical evidence, and maintain records of use and effects.
The Professional Staff at Prometheuz HRT, defined as qualified healthcare professionals with responsibilities including delivering healthcare services, may use certain drugs off-label, particularly in obesity management. These may include Human chorionic gonadotropin (hCG) and other peptides. While not FDA approved for long-term obesity management, there are studies demonstrating the safety and efficacy of these medications in this context, with no long-term cardiovascular risks or withdrawal issues. These studies are available upon request.
Purpose of Off-Label Drug Use:
The intention of using specific drugs off-label is to treat my medical conditions and enhance my quality of life. The Professional Staff may prescribe medications for various conditions, including but not limited to Andropause, Male hypogonadism, low testosterone, erectile dysfunction (ED), anxiety, stress, anger, depression, sleep disturbances, weight loss, among others.
No Guarantees or Assurances Regarding Results from Treatment
Neither the Professional Staff nor Prometheuz HRT provides any guarantees or assurances about specific results from treatments and medications.
Adverse Reactions
Treatments and medications may cause side effects, which can vary in intensity among individuals.
Potential side effects of Human Chorionic Gonadotropin (hCG) and other peptides might include acne, enlargement of penis and testes, headache, restlessness or irritability, growth of pubic hair, mild swelling or water weight gain, depression, and breast tenderness or swelling.
Client's Responsibility in Case of Adverse Reactions
I am responsible for reporting any significant adverse reactions from medications or treatments to the Professional Staff and/or Prometheuz HRT. These should be reported during normal business hours. However, if the reaction is severe, I should seek immediate medical attention.
In case of experiencing significant adverse reactions from medications or treatments outside business hours, I agree to IMMEDIATELY contact the emergency department of my local hospital or call 911.
Treatment
Treatment and medications will only be provided if a clinical need is established. This determination is based on one or more factors: physician consultation, physical examination, and current medical history.
PLEASE READ EACH SECTION CAREFULLY. YOU MAY REQUEST A COPY OF THIS FORM FOR YOUR RECORDS.
THIS NOTICE EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Understanding Your Health Record/Information
This notice outlines the practices of Prometheuz HRT and its staff regarding your protected health information while you are a client. All staff members with access to your records are bound by this notice. Additionally, Prometheuz HRT and the Professional Staff may share medical information for treatment, payment, or healthcare operations as described in this notice.
We maintain a record of the care and services you receive at Prometheuz HRT. We recognize that your medical information is personal and are committed to protecting it.
This notice details the ways in which we may use and disclose medical information about you, and describes your rights and our obligations regarding the use and disclosure of your medical information.
While your health record is physically held by Prometheuz HRT, the information it contains belongs to you. You have the right to:
Prometheuz HRT'S RESPONSIBILITIES
In addition to the above, Prometheuz HRT is also required to:
The following categories detail how we may use and disclose medical information about you without your authorization. Not every use or disclosure in a category will be listed, but all permitted uses and disclosures should fall within one of these categories:
We will not use or disclose your health information without your written authorization, except as described in this notice. Additional circumstances may also require your written authorization.
Instances requiring your additional written authorization, such as disclosures for marketing purposes, are uncommon but may occur.
For more information or to report a problem, you may contact Prometheuz HRT using the contact information provided in our Notice of Privacy Practices.
If you believe your privacy rights have been violated, you can file a complaint with Prometheuz HRT or with the Secretary of Health and Human Services. Filing a complaint will not result in retaliation.
This notice is effective as of January 1, 2022.
I acknowledge that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain privacy rights regarding my protected health information. I understand that this information will be used to:
INTRODUCTION
Telemedicine at Prometheuz HRT involves using electronic communications to enable healthcare providers at different locations to exchange patient medical information to improve care. This includes primary care practitioners, specialists, and subspecialists.
The information used in telemedicine may include:
We use electronic systems with network and software security protocols to protect the confidentiality of patient identification and imaging data, and include measures to safeguard the data against corruption.
As with any medical procedure, telemedicine carries potential risks. These include, but are not limited to:
I have read and understood the information provided above regarding telemedicine. I have had the opportunity to discuss it with my physician or designated assistants, and all my questions have been answered satisfactorily. I hereby give my informed consent for the use of telemedicine in my medical care.
Telemedicine Authorization
I hereby authorize Prometheuz HRT to utilize telemedicine in my diagnosis and treatment.
Client Contact Authorization
Please note that Prometheuz HRT does not disclose or sell any client protected health information to any third-party business or online database.
I, the undersigned, authorize Prometheuz HRT to contact me regarding aspects of my care, including information requests, payment or benefits verification, and appointment reminders. I understand that Prometheuz HRT may leave messages on my home or cell phone, or send reminders via U.S. mail, email, or text message.
Preferred Method of Communication
I acknowledge that Prometheuz HRT may use email or text messages for communication about my treatment and for marketing purposes. This may include appointment reminders, health reminders, feedback requests, newsletters, and other practice-related information.
I understand that this authorization will remain in effect until I either submit a subsequent Client Contact Authorization changing my above-stated preferences or I revoke or withdraw this authorization in writing. To do so, I must send written notice to the Practice at the email or mailing address listed in the Practice's Notice of Privacy Practices.
I acknowledge and agree that the Practice and its employees, officers, and physicians are released from any legal responsibility or liability resulting from the authorized disclosure of my health or billing information.
I have read this form in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either declined the opportunity to do so or had all my questions answered to my satisfaction.
