In
consideration of instructs Palm Beach Life Extension,
Inc. (“PBLE”) providing the undersigned patient (“Patient”)
with medical management, administrative and referral services,
Patient acknowledges and agrees to the following terms
and conditions contained in this Patient Authorization
Agreement (“Agreement”). With this Agreement, Patient
submits with this Agreement an accurately completed Medical
History Form (“MHF”). Patient agrees to respond to truthfully,
accurately and completely in completing the MHF and acknowledges
that failure to provide truthful, accurate and complete
information on the MHF or to PBLE or the physicians referred
by PBLE could result in inappropriate treatment.
Patient authorizes and PBLE to obtain on my behalf medical
laboratories, diagnostic testing, physicians and dispensing
pharmacies. In addition, Patient authorizes and instructs
PBLE and physicians referred by PBLE (“Physicians”) and
dispensing pharmacies obtained on my behalf to provide
medical care and prescribed pharmaceuticals based on the
MHF, laboratory diagnostic tests, and other information
submitted to PBLE under this Agreement. Patient agrees
to present photo identification upon any blood testing
pursuant to a PBLE or Physician test requisition. Patient
acknowledges that therapies and laboratory and diagnostic
testing services supplied or obtained by PBLE, and medical
services provided to me by Physicians, are not covered
or reimbursed by Medicare or other insurance.
Patient acknowledges that PBLE’s employees and agents are
not licensed physicians and that Physicians obtained on
my behalf by PBLE are independent contractors, which will
be compensated by Patient with funds provided to PBLE.
Patient acknowledges that PBLE does not practice medicine
and that PBLE is a medical management, adminsitration and
referral service and does not direct, control or influence
the treatment decisions made by Physician. I further
understand and agree that PBLE and Physicians are rendering
the medical care, services and treatment and that PBLE
is instructed and authorized to arrange for the prescribed
pharmaceuticals to be dispensed and sent to me by any
pharmacy in my country of residence. Patient covenants
and agrees to comply with the method of instructions,
treatment and dosage schedules prescribed by Physician,
to immediately cease any medical treatment prescribed
by Physician in the event of any adverse reaction or side
effect arising from prescribed treatment, and to immediately
provide PBLE and Physician with written notice via fax
to 561-721-1141 of any such adverse reaction or side affect.
I further acknowledge and agree that PBLE 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 PBLE and Physician have
made no guarantees or warranties with respect to the above-described
diagnostic testing, analysis of test results, examination
of medical history or hormone treatment. Patient acknowledges
that the hormone blood level objective sought as a result
of Patient’s hormone replacement therapy, as prescribed
by Physician, may be at the highest level of a standard
reference range for Patient’s age and sex, or, in some
cases, above such range, to the level of a younger person,
and that such range is experimental and may not render
any benefits, but may result in unknown, adverse results.
Patient is aware of the nature, risk and possible alternative
methods of treatment, possible consequences, and possible
complications involved in such hormone replacement treatment.
Patient acknowledges that recombinant human growth hormone
replacement therapy involves the use of a medical drug
approved for one purpose for a new and different purpose
in an effort to obtain a desired objective of medical
treatment. Nonetheless, Patient consents to such care
and treatment, and executes this Agreement with a complete,
informed understanding of such hormone replacement therapy
for the purpose of authorizing Physician to administer
such treatment to relieve body ailments and attempt to
enhance Patient’s physical condition and health. Patient
further acknowledges that the methods of medical treatment
offered by PBLE and Physician are not accompanied by any
claims, guarantees, promises or warranties.
Patient is freely seeking medical consultation via the
Internet and acknowledges and consents to Physician reviewing
Patient’s medical history without having the opportunity
to conduct an in-person physical examination. Patient
solicits PBLE for a specific prescription medication to
treat an already-identified medical or cosmetic condition.
Patient acknowledges that Physician may not be licensed
to practice medicine in Patient’s state or country of
residence. Further, Patient agrees that Physician’s consultations,
diagnoses, and treatments will be deemed to have occurred
in Florida, where physician is licensed to practice medicine.
Patient represents that he or she is under the care of
a primary care physician and that Physician will not rely
or substitute the advice of Physician should it conflict
with the advice given to me by Patient’s primary care
physician. Before taking any medication prescribed by
Physician, Patient agrees to have a comprehensive physical
examination by his or her primary care physician. Patient
agrees to notify his or her primary care physician and
advise such physician that Patient is undergoing hormone
replacement therapy.
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 HAS
DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This
is permitted under Florida law subject to certain conditions.
Florida law imposes penalties against noninsured 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 PBLE is not responsible
for the negligent or intentional acts or omissions of
any health care provider or supplier that Patient is referred
or for any action or inaction taken by Patient, that the
total liability of PBLE, its officers, directors, employees,
agents and stockholders is limited to the purchase price
of any products through PBLE, Physicians or pharmacies,
and that PBLE and Physicians will not be liable for any
direct, indirect, special, incidental, consequential,
or punitive damages. During Patients relationship with
PBLE and Physician, PBLE and Physician will convey to Patient
a range of proprietary business information, including,
confidential disclosures and trade secrets business practices
and PBLE’s customers and suppliers (“Confidential Information”).
No matter how received by Patient during the parties’
relationship, Patient agrees that Confidential Information
is confidential, proprietary and uniquely valuable to
PBLE and gravely affects the conduct of business of PBLE
and PBLE’s goodwill. Patient agrees not to disclose, divulge
or communicate, in any fashion, form, or manner, either
directly or indirectly, any of 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 if the terms of this paragraph are
breached, PBLE shall be conclusively deemed to be irreparably
injured and shall be entitled to an injunction restraining
Patient from disclosing any of the Confidential Information
and to liquidated damages in the amount of Ten Million
Dollars ($10,000,000.00). Patient agrees that the amount
of PBLE’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 liquidated damages are not a penalty.
Based on the above-understanding, Patient agrees to release
PBLE, 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 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 the Palm
Beach 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 and merges all prior and contemporaneous
agreements and discussions between the parties. Any and
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 held invalid
or unenforceable in any jurisdiction, the remainder hereof,
and the 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 PBLE and Physician and their respective
officers, directors, employees, stockholders, assigns,
successors and affiliates (“Indemnified Parties”) from,
against and in respect of all liabilities, losses, claims,
damages, punitive damages, causes of action, lawsuits,
administrative proceedings, investigations, demands, judgments,
settlement payments, deficiencies, penalties, fines, interest
and costs and expenses suffered, sustained, incurred or
paid by the Indemnified Parties in connection with, resulting
from or arising out of, directly or indirectly, PBLE and/or
Physician’s rendering medical care, services, advice,
and/or treatment, Patient’s failure to disclose all relevant
information regarding Patient’s medical and physical condition,
acts or omissions of PBLE or Physician, harm or injury
resulting from medical care or pharmaceuticals provided
directly or indirectly by PBLE or Physician. Patient is
aware of potential side effects associated with the above-described
treatment, accepts all risks involved in taking medication
and will not seek indemnification or damages from the
Indemnified Parties there from. |
HGH Info. 
