This agreement between (patient) and Medical Health establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" orâ€ť scheduled" medications. HRT Medical Solutions and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician 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.
Before submitting, please verify all the information is correct and print this form for your records. Patient agrees and consents to conduct business and transactions with Medical Health by electronic means, Electronic signature confirms authorization and agreement to the terms and conditions referenced above. This form is for pre-qualification only and a hand signed document is required for final approval by our physicians.