I, the undersigned
patient (patient) hereby agree and expressly authorize
South Beach Rejuvenation And Health Inc. to secure
a medical laboratory, physician and dispensing office/pharmacy
to provide my diagnostic testing, medical care and
if indicated, prescribed pharmaceuticals based on my
completed medical history form and any laboratory diagnostic
tests obtained through South Beach Rejuvenation And
Health Inc. I understand that South Beach Rejuvenation
And Health shall pay such physician as an independent
contracting physician, to render my medical services
from funds I pay to South Beach Rejuvenation And Health
Inc.. I further understand and agree that the independent
contracting physician, and not South Beach Rejuvenation
And Health Inc., is rendering the medical care, services
and treatment to me. South Beach Rejuvenation And Health
is instructed and authorized to obtain the necessary
medications prescribed by said medical doctor by causing
them to be dispensed directly to me and/or sent to
me by any pharmacy in the country of my residence.
I specifically hold harmless and waive any and all
claims or defenses against South Beach Rejuvenation
And Health Inc. or the treating medical physician selected
by South Beach Rejuvenation And Health Inc. I hold
harmless and waive any and all claims or defenses against
South Beach Rejuvenation And Health Inc., a licensed corporation, its directors, officers, shareholders,
employees, agents, contractors, contracting physicians
and contracting medical laboratories for any harm or
injury I sustain from any act or omission of said treating
medical doctor or other party. I also hold harmless
and waive any and all claims or defenses against any
treating and prescribing medical doctor selected by
South Beach Rejuvenation And Health Inc. to render
medical services for me for any harm or injury I sustain
as a result of treatment rendered by said doctor. I
also hold said treating physician harmless and waive
any and all claims and defenses for injuries or illnesses
I sustain as a result of my failure to comply with
the method of treatment and dosage schedule prescribed
by said doctor or from my failure to disclose all relevant
facts to said doctor. I agree to immediately cease
any medical treatment prescribed by said medical doctor
in the event of any adverse response or side effect
arising from prescribed treatment and provide immediate
written notice to South Beach Rejuvenation And Health
Inc. via phone and/or fax to South Beach Rejuvenation
And Health Inc.. I further agree to comply with prescribing
instructions for use of medications.
I, the undersigned Patient, understand and acknowledge
that the practice of medicine is not an exact science
and that diagnosis and treatment may involve risks or
injury. I acknowledge that no promises, assurances or
guarantees have been made to me as to the results of
diagnostic testing, analysis of test results, examination
of medical history or treatment by South Beach Rejuvenation
And Health Inc. or any treating or prescribing medical
doctor provided to me by South Beach Rejuvenation And
Health Inc. I understand that the hormone blood level
objective sought to result from my hormone replacement
therapy, as prescribed by my treating medical doctor
may be the highest level of standard reference range
for my sex and age, or an even higher hormone blood level
normally found in a person younger than myself. I understand
that hormone replacement therapy for the purpose of elevating
my hormone blood levels to the highest level of standard
reference range for my age and sex, or above such range
to the level of a younger person, is experimental and
may not render any benefits, but may result in unknown
adverse results.
I am aware of the nature, risk, possible alternative
methods of treatment, possible consequences, and possible
complications involved in my treatment. In understand
that recombinant human growth hormone replacement for
adults involves the use of a medical drug approved for
one purpose for a new and different purpose in an effort
to obtain sought objective of medical treatment. Nevertheless,
I consent to such care and treatment, and I execute this
form with complete informed understanding and for the
purpose of authorizing the medical doctor obtained for
me by South Beach Rejuvenation And Health Inc. to administer
to me for the relief of my body ailments and to enhance
my physical condition and health. I consent to receipt
of foreign-related versions of any prescribed drug approved
for medical use in the country of my residence. I understand
that the methods of medical treatment offered or provided
are not accompanied by any claims, guarantees or promises.
I agree to present my photo identification at any time
my blood is drawn pursuant to a South Beach Rejuvenation
And Health Inc. test requisition.
I understand that medical information revealed by me
may be used for continued medical research purposes,
but that I will not be personally identified at any time.
I understand that a prescribed drug ordered by me from
South Beach Rejuvenation And Health Inc. may be dispensed
to me by a pharmacy in my country.
I understand that South Beach Rejuvenation And Health
Inc. and doctors obtained to provide medical treatment
have elected not to carry malpractice insurance due to
the unique and unconventional medical treatments designed
primarily to be preventative and non-invasive. With respect
to any Florida medical doctors rendering or prescribing
my treatment at the request of South Beach Rejuvenation
And Health Inc. this notice is provided pursuant to S.458
320 Florida Statute. I expressly agree that the jurisdiction
and venue for any medical claim, legal or equitable claim
or any type whatsoever, or any dispute regarding pharmaceuticals,
physicians, physicians services, medical laboratories,
or any services or products provided to me by South Beach
Rejuvenation And Health Inc. its contracting pharmacies
or any services rendered by any medical doctor it selects
for me shall be exclusively by binding arbitration in
South Beach Rejuvenation And Health Inc. in Palm Beach
County, Florida USA. I consent to the transfer and removal
of any claim or action brought by me against South Beach
Rejuvenation And Health Inc. ,its physicians, contractors,
medical laboratories, officers, directors, and share-holders
to binding arbitration in South Beach Rejuvenation And
Health Inc. West Palm Beach, Florida, USA. Further, I
agree to pay all costs and reasonable attorney’s
fees incurred by any party against whom I bring a claim
or action in violation of the terms of this instrument
or related to the transfer, removal, change of venue
of any claim brought by my against any party to venue
in South Beach Rejuvenation And Health Inc. West Palm
Beach, Florida, USA as such costs are incurred on a weekly
basis, without exception or assertion of any legal or
equitable defense on my part or any legal counsel obtained
to represent me. Jurisdiction and venue for any action
brought against the Patient or its principal, by South
Beach Rejuvenation And Health Inc., its officers, directors,
contracting physicians or laboratories is South Beach
Rejuvenation And Health Inc. West Palm Beach, Florida,
USA.
The pharmaceuticals and laboratories blood testing services
supplied by South Beach Rejuvenation And Health Inc.,
and medical services provided to me by treating medical
doctors may or may not be covered or reimbursed by Medicare
or other insurance. In any case, South Beach Rejuvenation
And Health Inc. will not submit insurance claims on behalf
of the patients.
In consideration of South Beach Rejuvenation And Health
Inc. undertaking to render the undersigned patient any
administrative or any other services in any way to this
agreement, or South Beach Rejuvenation And Health Inc.
disclosing information or methods of treatment to patient
(either of which are deemed sufficient consideration
for this agreement), then, in the event any court determines
that the undersigned patient sought medical treatment
or medical prescriptions through South Beach Rejuvenation
And Health Inc. for possible or apparent purpose, directly
or indirectly, of deception, assisting any investigation,
or the rendering of any type of assistance to, or disclosing
any information pertaining to South Beach Rejuvenation
And Health Inc., its procedures, officers, directors
or medical protocols, to any news organization, possible
or actual competitor, any type of governmental agency,
any investigator or any other party for the possible
or apparent purpose of securing any information, confidential
or otherwise, about South Beach Rejuvenation And Health
Inc., it’s officers, directors, shareholders, affiliates,
banking relationships, contractors, medical laboratories,
contracting physicians, medical protocols, sources of
pharmaceuticals, proprietary medical treatment protocols
or South Beach Rejuvenation And Health Inc.’ system
of pharmaceuticals procurement, distribution, and dispensing,
then the undersigned Patient knowingly, expressly and
irrevocably consents to a judgment in favor of South
Beach Rejuvenation And Health Inc., it’s officers
or any party proceeding under the authority of this instrument,
of liquidated damages, jointly and serially against the
undersigned patient, as well as, any express or apparent
principal of patient (including Patient’s employer)
as an authorized or apparent agent of his principal or
employer, in the amount of Five Million Dollars, ($5,000,000.00),
which liquidated damage amount is hereby accepted by
the undersigned as a reasonable amount for engaging in
any such acts or deception and because they are difficult
to ascertain. The undersigned patient engaged in such
deception or any of the above described acts, agrees
on behalf of himself and his principal, to pay all reasonable
attorneys’ fees costs incurred by any person or
entity to enforce this agreement. This agreement represents
the complete and entire agreement between the parties
to it.
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