Pre-Placement Physical Exam

Patient Name:
DOB:	/ / (dd)/(mm)/(yyyy)
Email
Address:
City - Zip code
Resting Heart Rate:
Blood Pressure:	Normal Elevated
Highest Reading:	/
Height:	ft in.
Weight:	lb.

Physical Readings

General Appearance:	Normal	Abnormal
HEENT:	Normal	Abnormal
Lymph Nodes:	Normal	Abnormal
Chest:	Normal	Abnormal
Breast:	Normal	Abnormal
Lungs:	Normal	Abnormal
Heart:	Normal	Abnormal
Abdomen:	Normal	Abnormal
Genitalia:	Normal	Abnormal
Testes:	Normal	Abnormal
Spine:	Normal	Abnormal
Extremities:	Normal	Abnormal
Neurological:	Normal	Abnormal
Skin:	Normal	Abnormal
Prostate:	Normal	Abnormal
Notes

Exam Results:	Normal	Abnormal
Date	/ / (dd)/(mm)/(yyyy)

Examiner’s Signature:
Examiner’s Printed Name:
Examiner’s Address:
Examiner’s Phone:

NOTICE

Maxim Rejuvenation and other health organizations are required to keep your health information confidential. If you have authorized the disclosure of your health information to someone who is not legally required to keep it confidential, it may no longer be protected by state or federal confidentiality laws.

MY RIGHTS

• I understand this authorization is voluntary. Treatment may not be conditioned on signing this authorization except if the authorization is for 1) conducting research related treatment, 2) creating health information to provide to a 3rd party.
• I may revoke this authorization at any time, provided I do so in writing and submit to Maxim Rejuvenation Inc.. The revocation will take effect when MRI receives it.

•

I have read and accepted the Maxim Rejuvenation Inc. Privacy Policy Agreement
•

I have read and accepted the Patient Authorization for Medical Care/Treatment Agreement

Email
Contact telephone
Patient Signature
By typing my name in the box, titled, Electronic Signature, I acknowledge that by doing so this is to be considered the same as me physically signing my name. I, therefore, agree to all the terms, of said agreement, contained within. I also swear that the information that I have given is true and correct.
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Disclaimer: Please be advised that by filling out the necessary forms, and by submitting to labwork, and/or physical exam, and their related expenses, in no way guarantees that you will obtain medications from the physician affilites of MRI. These forms, and initial expenses, are required so that it may be determined whether or not you meet the criteria which are medically necessary to obtain medications. We write this disclaimer so that there is no misunderstandings between potential patients of MRI, and it's physician affiliates.