Cell Phone (Must be a cell phone to receive messages) *
Please provide a cell phone message so we can SMS text you important notifications.
MM slash DD slash YYYY
Please select an item from the following list: Mr. Ms. Mrs. First name Middle name or Initial Last name Gender Male Female Date of birth
MM slash DD slash YYYY
Please do not use this for your cell phone. Enter your cell phone in the Cell Phone field to recieve important SMS notifications.
Consent for Semaglutide or Human Chorionic Gonadotropin Assisted Weight-Loss Program and/or Sermorelin Therapy or any other prescribed medication.
By my signature below I do willingly request and consent to Semaglutide, HCG, B12, Ipamorelin, BCAA, Glutathione, Sermorelin with GHRP-2, GHRP-6, or both, and Lipotropic L-Carnitine injections or any other prescribed medication and a specific diet for the purpose of losing weight. To experience success on this program it is mandatory that I follow the diet protocol explicitly. I understand that there is no warrant or guarantee of results due largely to off-site administration and patient-controlled application.
1. I understand that as part of this program I will be required to complete a Medical History, listen to an orientation of the program where I will be instructed on how to administer the injections myself, or make arrangements to have someone assist me. I understand that initial blood tests may be required in order to rule out any conditions that would disqualify me from the program or require any prior treatment before starting the program. I agree to immediately report any problems that might occur to my counselor or coordinator as well as my Primary Physician during the treatment program.
2. I understand that there could be risks involved, as there are with all medications. Failure to comply with the dosage recommendation and dietary restrictions could alter the weight loss results.
3. I agree that I am, and will be, under the care of my primary medical provider for all other conditions. I understand that the medical providers who administer the HCG, Sermorelin, or any program cannot replace my regular Primary Care Physician or General Practitioners or other specialists in Family Medicine or Internal Medicine.
4. I understand that HCG is not FDA approved for weight loss. I also understand that there is currently limited medical evidence to support the use of HCG for this purpose. The FDA disclaimer states "HCG has not been demonstrated to be an effective adjunctive therapy in the treatment of obesity. There is no substantial evidence (although some good research does exist!) that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.
5. I understand that I will only be prescribed Semaglutide, HCG, Sermorelin, L-Carnitine, Ipamorelin, GHRP2, GHRP6, various vitamins, and B12 for treatment with the Assisted Diet program and will not be prescribed any other type of controlled prescription medications of any kind. We are sometimes asked by patients to provide or renew other medications (such as painkillers or anti-depressants), which were originally ordered by other medical providers. We are not able to comply with such requests.
6. I understand that treatments for weight loss are rarely covered by insurance companies. We do not accept or bill insurance for this program.
7. I understand that results may vary and I understand that any requests for a full or partial refund will NOT be honored. Your office use or prescription is in your individual name and cannot be returned.
8. I have read and understand all of the above statements and conditions and have been informed of potential side effects and risks that may be associated with the diet protocol. I fully understand what I am signing and hereby request and consent to weight-loss treatment using Semaglutide,HCG, Sermorelin, L-Carnitine, B12, and other offered treatments. I have disclosed my full medical history and I have been made aware of the benefits, side effects and/or rare possible adverse reactions of various treatments including Semaglutide,HCG, Sermorelin, L-Carnitine, B12 injections and other offered treatments on our site.
9. SEMAGLUTIDE CONTRAINDICATIONS! I UNDERSTAND THAT IF I HAVE ANY OF THE FOLLOWING I SHOULD NOT TAKE SEMAGLUTIDE INJECTIONS: Conditions: diabetic retinopathy, a type of damage to the eye from diabetes, low blood sugar, decreased kidney function, pancreatitis, medullary thyroid cancer, multiple endocrine neoplasia type 2, family history of medullary thyroid carcinoma, kidney disease with likely reduction in kidney function,.
I acknowledge that all statements provided on these forms, and the Confidential Health History Forms are true and accurate to the best of my knowledge and that my treatments will be based on the information provided herein and if I willingly withhold information, I accept full liability for any consequence that may arise therefrom.
Required Signature Emergency contact name
Emergency contact relationship Emergency contact phone I have read and fully understand the above information related to participation in the Semaglutide or HCG Assisted Diet Weight Management Program and the use of Sermorelin, L-Carnitine, B12 injectables and all other medications offered. I have had the opportunity to ask questions and received answers regarding any issues. I understand the specifics and limitations as described in this document. I accept all of the specific policy rules. Required Signature Hidden Medical History Please check all that apply to you. VERY IMPORTANT: Are you under a doctor's care at the present time? No Yes If yes, for what? Surgeries & Other Hospitalizations Reason/Diagnosis Year Hospital Reason/Diagnosis Year Hospital Reason/Diagnosis Year Hospital Reason/Diagnosis Year Hospital Allergies Allergies to medication
Please list any medications you have known allergies to:
Medication name Purpose Reaction Medication name Purpose Reaction Medication name Purpose Reaction Medication name Purpose Reaction Prescribed Medications
Prescribed Medications, over-the-counter drugs, dietary supplements (include vitamins, inhalers, etc.)
Medication name Dose Frequency Medication name Dose Frequency Medication name Dose Frequency Medication name Dose Frequency Behavior Style: Please select which one best describes you You are always calm and easygoing You are usually calm and easygoing You are sometimes calm with frequent impatience You are seldom calm and persistently driving for advancement You are never calm and have overwhelming ambition You are hard-driven and can never relax Which best describes your exercise habits? Inactive - No regular physical activity with a sit-down job Light activity - No organized physical activity during leisure time. Moderate activity - Occasionally involved in activities such as weekend golf, tennis, jogging, swimming or cycling. Heavy activity - Consistent lifting, stair climbing, heavy construction, etc., or regular Participation in jogging, swimming, cycling or active sports at least three times per week. Vigorous activity - Participation in extensive physical exercise for at least 60 minutes per session 4 times per week. Are you dieting now? No Yes Third Choice If yes, what diet program? How many meals do you eat in an average day? Rank your fat intake: Low Medium High Rank your salt intake: Low Medium High Rank your caffeine intake: Low Medium High What types of caffeine do you drink? How many cups/cans per day? Do you drink alcohol? No Yes Do you use cocktail mixers? No Yes If yes, what kind? Cigarettes - packs/day? 1-2 3-4 5+ None Other Tobacco Products? No Yes How many years? Women Only - Are you pregnant, trying for pregnancy, or breast feeding? No Yes Weight History What is the main reason you decided to lose weight? When did you begin gaining excess weight? Provide reasons if known What do you think is the main cause of your weight problems? Describe other weight loss programs or previous diets you have followed or attempted Is your spouse, fiancé/fiancée, or partner overweight? If so, by how many pounds List any food allergies or foods that you avoid What foods do you crave more than most others? These are your Passion Foods. What are your snack habits? Do you tend to eat more when you are under a stressful situation? No Yes Do you think you are currently experiencing a stressful situation or emotional upset in your life? Explain. What do you feel are your obstacle(s) to successful weight loss? Patient authorization agreement
I HEREBY DECLARE to the best of my knowledge, belief and intention, that the information I have submitted, on the Professional Health Academy Personal Medical History Form and the Terms and Conditions forms are correctly recorded, complete and true. I agree that the Company, believing them to be true, shall rely and act upon them accordingly and make determinations based on my responses and answers. My accurate medical history information is required so that my doctor and staff have accurate current health information available. This information will be analyzed and reviewed by my diet physician and counselor who can then properly review, qualify, and treat me for all diet related services. I understand that this review is only applicable to the diet regimen with HCG and that all other medical situations will be the responsibility of my primary care physicians. Professional Health Academy is a license Health Care Clinic Establishment in Florida that owns and operates the website this intake form is on. License information and verification is available upon request.
Required Signature Consent for Human Chorionic Gonadotropin Assisted Weight-Loss Program and any other offered weight loss program with medications
(A) WARNING: RAPID WEIGHT LOSS MAY CAUSE SERIOUS HEALTH PROBLEMS. RAPID WEIGHT LOSS IS WEIGHT LOSS OF MORE THAN 1.5 POUNDS TO 2 POUNDS PER WEEK OR WEIGHT LOSS OF MORE THAN 1 PERCENT OF BODY WEIGHT PER WEEK AFTER THE SECOND WEEK OF PARTICIPATION IN A WEIGHT-LOSS PROGRAM.
(B) CONSULT YOUR PERSONAL PHYSICIAN BEFORE STARTING ANY WEIGHT-LOSS PROGRAM.
(C) ONLY PERMANENT LIFESTYLE CHANGES, SUCH AS MAKING HEALTHFUL FOOD CHOICES AND INCREASING PHYSICAL ACTIVITY, PROMOTE LONG-TERM WEIGHT LOSS.
(D) QUALIFICATIONS OF THIS PROVIDER ARE AVAILABLE UPON REQUEST.
(E) YOU HAVE A RIGHT TO: ASK QUESTIONS ABOUT THE POTENTIAL HEALTH RISKS OF THIS PROGRAM AND ITS NUTRITIONAL CONTENT, PSYCHOLOGICAL SUPPORT, AND EDUCATIONAL COMPONENTS. RECEIVE AN ITEMIZED STATEMENT OF THE ACTUAL OR ESTIMATED PRICE OF THE WEIGHT-LOSS PROGRAM, INCLUDING EXTRA PRODUCTS, SERVICES, SUPPLEMENTS, EXAMINATIONS, AND LABORATORY TESTS. KNOW THE ACTUAL OR ESTIMATED DURATION OF THE PROGRAM. KNOW THE NAME, ADDRESS, AND QUALIFICATIONS OF THE PHYSICIAN,DIETITIAN OR NUTRITIONIST WHO HAS REVIEWED AND APPROVED THE WEIGHT-LOSS PROGRAM ACCORDING TO s. 468.505(1) (j), FLORIDA STATUTES.
Potential Risks and Side Effects: HCG will NOT be prescribed and is contraindicated if: You are pregnant, trying to become pregnant, or currently breast feeding. You have ever had any type of cancer or malignancy. You have Undiagnosed Uterine Bleeding. You have heart disease, a history of a heart attack, stroke, bleeding disorder, or blood clot. You are an Insulin-Dependent Diabetic (Individual Dependent)
You must inform your primary health care provider or seek immediate medical attention (as indicated) if any of the following occurs:
Allergic Reactions: If you experience a reaction to the injection, you may have sensitivity to HCG. Stop using HCG and seek medical attention immediately.
It is necessary for you to disclose any pre-existing condition in order to rule out any symptomatology that may not be related to the HCG. Also during an allergic reaction, the body produces excess fibrin which induces blood clotting, a potentially lethal situation.
Less serious side effects may occur and include: headache (often during the first week only); Feeling restless, irritable or fatigued (often during the first week only); Constipation; Increased urination; Mood swings (often during the first week only); Breast tenderness or swelling; Pain, swelling, redness, bruising or irritation where the injection is given; In some patients, temporary hair loss may occur as a result of rapid weight loss.
Other Drugs May Affect HCG There may be other drugs that can interact with HCG. Tell us about all prescription medication over-the-counter medications, vitamins and any type of supplements you presently use. Do not start taking any new medications or supplements without telling us. The use of steroids or antibiotics while on the program may reduce effectiveness and dramatically slow weight loss.
FDA Disclaimers and Required Communication to Patients "The FDA has not approved HCG Therapy to lose weight. "HCG HAS NOT BEEN DEMONSTRATED TO BE EFFECTIVE ADJUNCTIVE THERAPY IN THE TREATMENT OF OBESITY. THERE IS NO SUBSTANTIAL EVIDENCE (although some positive research does exist) THAT IT INCREASES WEIGHT LOSS BEYOND THAT RESULTING FROM CALORIC RESTRICTION, THAT IT CAUSES A MORE ATTRACTIVE OR "NORMAL" DISTRIBUTION OF FAT, OR THAT IT DECREASES THE HUNGER AND DISCOMFORT ASSOCIATED WITH CALORIE-RESTRICTED DIETS.
I understand that this diet protocol includes "off---label" use of the FDA approved medication HCG Human Chorionic Gonadotropin. I understand that this medication has not been approved for the purpose of weight loss but is approved by the FDA for other medical treatments. These treatments are approved for young boys or adult men with a condition of Hyper-Gonadism and in women as an aid in achieving pregnancy.
FDA understands that sometimes approved products are used to treat conditions that the products were not approved for (i.e., "off-label" uses). The "off-label" use of products usually presents greater uncertainty about both the risks or benefits because less information is available on safety and effectiveness. Unexpected adverse events may occur in this context. . ("Off---label" use means the use of FDA approved drugs for purposes other than those for which the FDA has approved them.) "Off---label" prescribing is a legal and common practice by physicians in the United States. What can consumers do if they have a complaint?
FDA urges both health care professionals and consumers to report harmful effects experienced from using HCG for weight loss to the FDA's Med Watch Adverse Event Reporting program by doing one of the following:
Complete and submit the report online: www.fda.gov/MedWatch/report.htm Download the form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178 Professional Health Academy Telehealth HIPAA Notice of Privacy Practice
This describes how your information may be disclosed and how you get access to this information.
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, and healthcare operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information, or PHI, is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related healthcare services. Uses and Disclosures of Protected Health Information Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operations of the physician's practice, and any other use required by law. Treatment: We will only use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides you care to you, or provide it to a physician whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Payment: Your protected health information will be used as needed to obtain payment for your health care services. Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician's practice. These activities include but are not limited to quality assessment, employee review, training of medical students, and licensing. For example, we may call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointments. We may use or disclose your protected health information in the following situations without your authorization: as required by law, public health issues, communicable diseases, health oversight, abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, organ donation, research, criminal activity, military activity, and national security. Under the law, we must also make disclosures to you, and when required by the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted & Required Uses and Disclosures will be made only with your authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Your Individual Rights: 1.You have the right to inspect and receive a copy of your protected health information. Our practice will accept such requests in writing. Under federal law, however, you may not inspect or receive a copy of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. 2. You have the right to request a restriction on the disclosure of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of our protected health information, your health information will not be restricted. You then have the right to use another healthcare professional. 3. You have the right to request to receive confidential communications from us by an alternative means or at an alternative location. 4. You have the right to obtain a paper copy of this notice from us. 5. You have the right to receive an accounting of certain disclosure we have made, if any, of your protected health information. We reserve the right to change the terms of this notice and will post any changes in our waiting areas. You then have the right to object as provided in this notice. Complaints: You may file any complaints with our Office Manager Javier Cuenca at 954-512-8572 or with the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. We will not retaliate against you for filing a complaint.
Professional Health Academy LLC Receipt of Notice of Privacy Practices
Professional Health Academy LLC reserves the right to modify the privacy practices outlined in this notice.
By signing below, I am indicating that I have read and understand the Notice of Privacy practices.
Patient Authorization Agreement
TERMS AND CONDITION
Your health is a very important personal issue, and we understand that confidentiality of your information is of the highest priority and of utmost importance. To protect your privacy, we have implemented and will follow specific security protocols and processes on every matter that is related to your files and information. We use the highest level of individual customer, electronic transfer and internet security features provided by Gravity Forms. They are specifically designed to guarantee your privacy and security to the very best of our ability. Our company policy is to not allow any unauthorized party access to any part of your personal financial or medical information without your written instruction. If you have a question on our security processes or protocols, please contact us immediately.
Nothing contained in this Web Site or in printed materials shall constitute an offer by Professional Health Academy LLC, its officers, employees, or affiliates to buy or sell products or services to you. No agreement to sell products or services shall be formed until an order is placed by you and then approved by Professional Health Academy LLC, its affiliates in the manner set forth in Professional Health Academy LLC'S specific ordering instructions. The terms of such agreement shall be those of Professional Health Academy established procedures or any such of our affiliate's standard terms and conditions. All product requests or orders are subject to all applicable law of the State of Florida.
PATIENT AUTHORIZATION AND CONSENT
In consideration of instructions from Professional Health Academy, hereinafter referred to as ("Coordinator) providing the undersigned patient, hereinafter referred to as ("Patient") with medical management, administrative or referral services, Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement ("Agreement") and supersedes all other instructions written or oral received from Professional Health Academy. With this agreement, Patient also submits an accurately completed Medical History Form hereinafter referred to as ("MHF"). Patient agrees to respond truthfully, accurately, and completely in completing the MHF or with any agent provided by Coordinator to assist in completing the form and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to Coordinator, the physicians, nurses or staff referred by Professional Health Academy could result in inappropriate treatment.
Patient authorizes Coordinator to obtain on my behalf medical laboratories or diagnostic testing when required, Physicians, and dispensing pharmacies. In addition, Patient authorizes and instructs Coordinator and Physicians hereinafter referred to as ("Physicians"), referred by Coordinator and any dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals if necessary are based on the MHF, laboratory diagnostic tests, and other information submitted to Coordinator and Physician under this agreement. Patient agrees to present photo identification upon any blood testing pursuant to a Physician's test requisition.
Patient acknowledges that therapies, laboratory, and diagnostic testing services supplied or obtained by Coordinator as well as medical services provided to me by Physicians or pharmacies, are not covered or reimbursed by insurance.
Patient acknowledges that Coordinators, employees, and agents are not licensed physicians and that licensed Physicians obtained for me by Coordinator are independent contractors, who will be compensated by patient with funds provided to Coordinator. Patient acknowledges that Professional Health Academy does not practice medicine and that they are a license health care clinic, medical management, administrative, consultant and referral service that does not direct, control, or influence the treatment decisions made by Physician. I further understand and agree that Coordinator is rendering services and that Coordinator is instructed by patient and is authorized by patient to arrange for the office use or prescribed pharmaceuticals if required to be dispensed and sent to my address by any pharmacy in my country of residence. All medical care and treatments are agreed upon by the Patient, the Physician, and the Patients personal Physician.
Patient acknowledges and assigns Professional Health Academy as a designee of the patient, to engage in discussion with the physician or the physician assistant regarding treatment options and the risks and benefits of treatment.
Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by the Physician, Patient further agrees to immediately cease any medical treatment prescribed by the Physician in the event of any adverse reaction or side effect arising from or believed to arise from the prescribed treatment, and to immediately provide Physician and Patients Personal Care Physician with written notice via e-mail to Physician at email@example.com or by telephone to 954-512-8572 of any such adverse reaction or side effect.
I further acknowledge and agree that Professional Health Academy is not liable for any negligent act or omission of the Physician. Patient acknowledges that diagnosis and treatment may involve risk of injury, and that Professional Health Academy and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history.
Nonetheless, Patient freely consents to such care and treatment, and executes this Agreement with a complete, informed understanding of the HCG Assisted Diet protocols for the purpose of authorizing Physician to administer such treatment to attempt to enhance Patient's physical condition and health based on Patients MHF. Patient further acknowledges that the methods of medical treatment offered by Physician are not accompanied by any claims, guarantees, promises, or warranties.
It is fully agreed and understood by the patient that personal office use or prescription products purchased through or obtained on my behalf require a medical approval or prescription and as such are NOT returnable or refundable under any circumstances under both Federal and/or State laws. It is unlawful for a pharmacy or clinic to accept the return of office use or prescription medications once they have left the control of the clinic or pharmacy.
Patient is freely seeking medical consultation via the Internet, phone, or direct contact and acknowledges, request and consents to Physician reviewing their medical history without having the opportunity to conduct an in-person physical examination. Patient solicits Coordinator to order any specific office use or prescription medication to take part in the HCG Assisted Diet, Semaglutide, or any other weight loss program. Further, Patient agrees that Physician's consultations, diagnoses, and treatments will be deemed to have occurred in Florida, and with the legal rules for Telemedicine in Florida.
Patient represents that he or she is under the care of a Primary Care Physician (PCP) and that the Physician will not rely or substitute the advice of any physician should that advice conflict with the advice given by Patient's Primary Care Physician. Before taking any medication patient agrees to have or to have had a physical examination by their (PCP). Patient agrees to notify his or her (PCP) and advise such (PCP) that they intend to begin the HCG Assisted Diet Program, Semaglutide, or any other weight loss program offered by Professional Health Academy.
Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. Physician, Coordinator, and Professional Health Academy have DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.
Patient acknowledges and agrees that Professional Health Academy is not responsible for the negligent or intentional acts or omissions of any health care provider, Physician or supplier that Patient is referred or for any action or inaction taken by Patient, and that the total liability of Professional Health Academy, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through Professional Health Academy, Physicians or Pharmacies, and that Professional Health Academy and Physicians will not be liable for any direct, indirect, special, accidental, consequential, or punitive damages.
During Patients relationship with Coordinator and Physician, Patient will receive a range of proprietary business information including, confidential disclosures, and trade secrets, business practices and Professional Health Academy LLC's associates and suppliers ("Confidential Information"). No matter how received by the Patient during the parties' relationship, Patient agrees that Confidential Information is confidential, proprietary, and uniquely valuable to Professional Health Academy LLC and could gravely affect the conduct of business of Professional Health Academy LLC and Professional Health Academy LLC's goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any Confidential Information or take any action that may result in disclosure of Confidential Information to any third-party person, firm, or business.
Patient agrees that the amount of Professional Health Academy LLC's actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such damages are a penalty.
Based on the above-understanding and my signature below, Patient agrees to release Professional Health Academy LLC, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physician's consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physician's consultation.
This Agreement shall be governed, construed, and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in Miami-Dade County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.
This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and discussions between the parties. All representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void, and of no effect.
If any provision of this Agreement or the application thereof to any person or circumstances is invalid or unenforceable in any jurisdiction, the remainder hereof, and all application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end the provisions of this Agreement shall be severable.
Patient covenants and agrees to indemnify, defend, protect, and hold harmless, and Physician and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates hereinafter referred to as ("Indemnified Parties") from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, any acts, directly or indirectly, by Professional Health Academy LLC, their staff and/or Physician's rendering medical care services, advice and/or treatment resulting from Patient's acts or omissions or failure to disclose all relevant information regarding Patient's medical and physical condition. Professional Health Academy LLC and Physician are released from any responsibility to patient that results from acts, omissions or failures of disclosure by Patient as mentioned above.
Patient is aware of potential side effects associated with the above-described diet treatment, accepts all risks involved in taking medication and the very low-calorie diet protocols and will not seek damages from the Indemnified Parties of this Agreement.
I the undersigned Patient have read and clearly understand and agree to all the above Terms and Conditions of this Agreement from Professional Health Academy LLC.
Required Signature Financial Policy
Please be advised that payment is due in full before starting the program. If paying with Credit or Debit, your charge will be from Professional Tutors Academy DBA Professional Health Academy, a licensed clinic in Miami, FL specializing in weight loss consulting and tutorials. There is no warrant or guarantee of results due largely to off-site administration and patient-controlled application of the diet program. Should this account be referred to an agency or an attorney for collection, you will be responsible for all collection costs, attorney's fees, and court costs. By submitting this intake form and moving forward with any order paid by credit or with debit card, you agree that any credit or debit card dispute should be resolved in favor of Professional Health Academy. By signing below, you are acknowledging that you have read and agree to our Financial Policy. We have a no refund policy and office use or prescribed medications cannot be returned. Our fees include the consultation, order processing, costs of medications prescribed, and cost of supplies.
Required Signature FILE UPLOADS Drivers License or Other Photo ID
Please upload a photo ID with your name and photo on it. Examples include: Drivers License, passport, student ID, Work ID, etc. Must have your name and photo.