Last revised May 31st, 2021
I agree and authorize BodyLogic to select and secure a medical laboratory for diagnostic testing, a prescribing telemedicine physician for medical recommendations, and a dispensing and compounding pharmacy based in the U.S. for selected pharmaceuticals.
I affirm that I have answered and will answer all questions truthfully regarding any and all completed medical history forms, just as I would in my local physicians office. I specifically hold harmless and waive any and all claims or defenses against BodyLogic or the treating telemedicine physican selected by BodyLogic and will not claim that the consulting physician acted unprofessionally or below the standard of care solely because the consulting telemedicine physician did not personally physically examine me; and am aware that said physician may be located and licensed in another state not of my residence.
I affirm I have fully disclosed all information concerning my health and medical history truthfully and therefore hold said consulting telemidicine physician harmless and waive any and all claims and defenses for injuries and/or illnesses I may sustain as a result of my failure to comply with method of treatment, dosing schedule, or failure to disclose all relevant facts and accurate information understanding this could adversely affect my physical and/or mental health by causing an adverse response or side effect. I understand and acknowledge as a BodyLogic patient I am responsible to continually update any changes that take place regarding my medical history.
I specifically hold harmless and waive any and all claims or defenses against BodyLogic, licensed corporation, its directors, officers, shareholders, employees, agents, contractors, telemedicine physicians , contracting laboratories and dispensing compounding pharmacy for any harm or injury I sustain from any act or omission of said treating/ consulting medical doctor or other related party. I understand, acknowledge, and am aware that there are risks as well as benefits to any medications, as well as future consequences and complications involved with standard treatment and especially with alternative methods of treatment.
I understand and completely acknowledge the practice of medicine, anti-aging medicine, and/or hormone replacement therapy, is not an exact science and that therapy for the purpose of elevating my hormone blood levels to the highest level of standard reference range for my age and sex, or even above such reference range to achieve levels of a younger person, is completely individualized. I understand and acknowledge that BodyLogic or said treating/consulting doctors have made no promises, assurances, or guarantees to me regarding my treatment and as this practice of elevating my hormone levels as being individualized, may not render any benefits, and can even result in unknown adverse effects or results presently and/or in the future.
I certify that I have had a recent physical examination by my primary physician, and will be responsible for forwarding said examinations to BodyLogic and said consulting physicians. I understand, acknowledge, and request that BodyLogic and its selected licensed telemedicine physicians act only in an adjunct consultative capacity, not to replace my primary care physician. I further certify that I will contact my primary care physician, or other local physicians or emergency personnel for any necessary care and intervention for any and all complications, difficulties, or adverse reactions regarding my treatment. I certify that any medications purchased are for personal use and will not stockpile or distribute any medications purchased to others.
I understand and agree to present my photo identification at any time blood is drawn pursuant to a BodyLogic testing requirement. I understand and agree that all online BodyLogic consultations, diagnosis, and treatment will be deemed to have occurred in the state where the BodyLogic consulting telemedicine physician is licensed and located to practice medicine.
Again, I understand and acknowledge all that I have read, certify that I am a competent adult of sound mind, and am 18 years of age or older, that I initiated contact with BodyLogic of my own free will and under no duress. I certify that I am authorized to use the credit card presented to BodyLogic for purchasing medications and that said medications will be dispensed directly to me from a licensed U.S. based compounding pharmacy.
I understand that any medications and/or supplies purchased are NON-REFUNDABLE
I understand that any laboratory testing once purchased is NON-REFUNDABLE.
FOR ALL MEDICAL EMERGICES CALL 911 IMMEDIATELY!!!!