HOW TO GET STARTED

Step 1 Call and speak to consultant about programs

Step 2 Fill out Medical History form on our website, or we can email, fax or mail

Step 3 Once we review completed Medical History form, we will schedule you to get required bloodwork/comprehensive medical evaluation. We have a national network of labs and will locate one close to you or schedule a phlebotomist to come to your location. If you already have bloodwork and it has all of the necessary tests required and is less than one year old we may opt to use it if the proper biomarkers meet our medical criteria.

Step 4 Once we receive and approve, your bloodwork/medical evaluation, we will review and help you design a program that it most suitable to you.

Step 5 Medications are ordered, we can ship next day. All prescriptions are processed by a US Pharmacy.

Step 6 Our Doctor or pharmacist , will contact you and make sure you understand side effects, dosages, and information on the individually designed protocols.

SECTION 1. PERSONAL INFORMATION

* Required Fields

		Advisor: *
First Name: *		Last Name: *
E-Mail: *		SSN#:
Address 1: *		Home Ph.:
Address 2:		Work Ph.:
City: *		Mobile:
State/Province: *		Fax:
Zip:		Ocupation
Country:

SECTION 2. CONFIDENTIAL MEDICAL HISTORY

MEDICAL HISTORY INFORMATION

Date of birth:*
Year:	Month: Day:
Weight:		Height:
Gender: *

PRIMARY PHYSICIAN INFORMATION

Physicians Name:		Phone:
Date of your last physical examination with your physician:

Family History: Does an immediate family member currently have or ever had any of the following? If yes, please check and explain below:

Lifestyle Information:	Yes	No	Details
Do You Smoke?
If Yes how much do you smoke per day?
Do you drink alcohol?
If Yes how much do you drink per week?
Are you taking over the counter supplements?
If Yes, list Name and Quantity per day/week:
Do you exercise regularly?
If Yes, please describe:

Diagnosed History of Disease: Do you currently have or ever had any of the following? If yes, please explain in the box below:

Choose Yes or No for each:	Yes	No
Any known deficiency including minerals and electrolytes
Use of medications: (if yes, list medications below)
Blood disorders:
Immune disorders:
Cancer:
Chemical Dependency:
Carpal Tunnel syndrome:
Lung disorder:
Orthopedic or muscle disorder including fracture or joint disorders
Heart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack:
Allergies to Medications:
Upper respiratory:
Edema / excess fluid retention:
Poor wound healing:
Emotional disorders / depression:
Renal disease:
Genital - Urinary disorder:
Other illnesses:
Hyperlipidemia:
Hypertension:
Neurological disorders, Thyroid, Diabetes or other endocrine, insulin resistance, or diabetes
Arthritis or bursitis
Please use this space to explain any Yes answers for allergies to medications, surgeries, hospitalizations, disease, or any additional information:

List all the medications you are taking: Please be specific (Name, dosage, etc.) or specify "none"

Prospective Patients: Please check the symptoms you hope to have improved through hormone replacement therapy (HRT).

MRAH DO NOT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT

Existing Patients : Please check the symptoms you have improved and hope to continue to improve through HRT.

Questions for Treatment: Do you currently have or ever had any of the following symptoms?
If Yes, please check and explain below:

	Yes	No
Decreased desire and ability to exercise:
Increasing sagging muscles or breasts:
Cold or heat intolerance:
Increasing wrinkles:
Decreased energy or endurance:
Increasingly stressed:
Decreased sense of well-being:
Decreasing size of testicals:
Decreasing memory:
Loss of interest in sex:
Decreasing muscle strength:
Muscle loss:
Loss of concentration, sociability, activity
Progressive osteoporosis, decreasing bone mass or stooped posture
Depression:
Sagging, loose or thin skin:
Difficulty sleeping:
Thinning or loss of hair:
Hot flashes:
Uro-genital atrophy:
Increased lack of drive:
Headaches/ Migraines:
Increasing fat deposits about abdomen and/or thighs:
Weight loss - Unexplained:
Increasing mood swings:
Currently Pregnant?
Other
Pain in ny joint or muscles
Please use this space to explain "other" and write any additional information:

SECTION 3. SIGNATURE

An Agreement Authorizing MAXIM Rejuvenation Inc. to select a treating and Prescribing Physician, Blood Testing Medical Laboratory and D ispensing Pharmacy

Patient's Informed Consent and Authorization for Medical Care and Hormone Replacement Therapy

Yes, I agree to the terms and conditions disclosed herein. *

Signature: Date: