Patient Booking Form

Name

This agreement between (“patient”) and KoreMe Anti-aging and aesthetics group LLC from here on known as (KoreMe) establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA “controlled” or “scheduled” medications. KoreMe and patient agree that these guidelines and conditions are an essential factor in maintaining a successful doctor/patient 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:
1. I understand that the prescribing physician must do a face-to-face evaluation. And to follow these guidelines I will fly/drive to the physician’s location for my evaluation to maintain treatment.

2. I understand that the medications I am receiving or will receive are prescribed for me based on diagnoses derived from my submitted medical history, 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.

3. I understand and agree that no medical treatment or medication provided to me by KoreMe will be used for the purposes of bodybuilding, performance enhancement or physical appearance.

4. I certify that the answers I provided to the health questions on the Health History form and otherwise to KoreMe and/or KoreMe affiliated physicians or 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.

5. 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.

6. 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 KoreMe and discontinue use until advised to resume usage by KoreMe. I voluntarily assume any and all possible risks, which may be associated with HRT.

7. I understand that patient coordinators of KoreMe and Licensed Physicians are available for questions and/or concerning during normal business hours throughout the course of my treatment.

8. I agree that the HRT medications furnished by KoreMe 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.

9. I will be able to purchase the medications from the pharmacy designated by KoreMe and the pharmacy will send medications directly to me. I understand I have the right to purchase my medications from a pharmacy of my own choice, I must notify KoreMe in writing of my intention to do so and include the name and phone number of the pharmacy in my request.

10. I agree and understand that federal regulations prohibit the return of prescribed medications.

11. I understand that HRT treatment and medications are not covered by health insurance. I agree that all services and medications provided by KoreMe 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.

12. I agree that the KoreMe 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 KoreMe will be in conjunction with the care provided by my current PCP.

13. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container.

14. I understand that KoreMe 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. Agreeing to lab work does not automatically qualify patient to clinically necessity and/or prescription.

I have read and agree to the terms above.

Printed Name:

Date

Which of the following symptoms apply at this time?
1 being minor and 5 being major problem

Do you have any other major symptoms?

KOREME ANTI-AGING & AESTHETICS GROUP LLC

HEALTH INFORMATION AUTHORIZATION

Patient Name

Address

Date of Birth

Date of Request

As required by the HIPAA Privacy Regulations, KoreMe Anti-aging and Aesthetics
Group LLC may not use or disclose your protected health information without your
authorization.
1. I hereby authorize KoreMe Anti-aging and Aesthetics Group LLC or any of its employees to
use or disclose my Patient Health Information to the following person(s), entity (ies), or
business associated with this office:
(List laboratories, physicians that will receive information) : (PLEASE INSERT BELOW)
2. Patient Health information authorized to be disclosed:
Lab Work, medical history, physical examinations, diagnoses on therapies,
telemedicine encounters, and tele-health encounters.
3. For the specific purpose of:
Bio-identical hormone therapy, Andropause Treatment, Menopause Treatment, and
Hormone Deficiency Treatment.
4. I understand that the information disclosed above may be re-disclosed to additional parties
and no longer protected for reasons beyond our control.
5. Unless otherwise revoked, this Authorization will expire on: (PLEASE INSERT BELOW)
6. I understand that I have the right to:
a. Revoke this authorization by sending written notice to KoreMe Anti-aging and Aesthetics
Group LLC and that revocation will not apply to information that has already been released
in response to this authorization.
b. Inspect a copy of Patient Health information being used or disclosed under federal law.
c. Refuse to sign this authorization.
d. Receive a copy of this authorization.
e. Restrict what is disclosed with this authorization.
7. I understand that my refusal to sign this document will not affect my treatment, payment,
and enrollment in a health plan, or eligibility for benefits merely because I do not provide
authorization to use or disclose protected patient health information.
8. By signing below, I understand and acknowledge that:
a. I have read and understand this Authorization.
b. If I have questions about disclosure of my protected information, I may contact Dr. DiSanto
at KoreMe Anti-aging and Aesthetics Group LLC at the phone number below.

(List laboratories, physicians that will receive information)

Authorization will expire on:

Date

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