CommentsThis field is for validation purposes and should be left unchanged.Contact InformationName(Required) First Last Phone(Required)Email(Required) Enter Email Confirm Email Shipping Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Tell Us About YouAge(Required)Date Of Birth(Required) Sex Assigned At Birth(Required)Please ChooseMaleFemaleMarital Status(Required)Please ChooseSingleMarriedDivorcedOtherHeight (Inches)(Required)Weight (lbs)(Required)How Did You Hear About Us?Untitled(Required) Family/Friend Website The Westword Facebook Life On Capitol Hill Craigslist Renewal Letter Culture 5280 Magazine Other Emergency ContactLocal Friend or Relative(Required)Phone(Required)Relationship To You(Required)Privacy Statement Please Read and Acknowledge the Privacy Statement Below THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY. IF YOU WOULD LIKE A COPY OF THIS NOTICE PLEASE LET US KNOW AND WE WILL BE HAPPY TO SUPPLY YOU WITH A COPY. 1. OUR PLEDGE REGARDING MEDICAL INFORMATION The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our organization. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share medical information about you. We also describe your rights and certain duties we have regarding the use and disclosure of medical information. 2. OUR LEGAL DUTY The Law Requires us to: ✓ Keep your medical information private. ✓ Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information. ✓ Follow the terms of the current notice We Have the Right to: ✓ Change our privacy practices and the terms of this notice at any time, provided the changes are permitted by law. ✓ Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes. Notice of Change to Privacy Practices: ✓ Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request. 3. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. WE WILL NOT USE OR DISCLOSE YOUR MEDICAL INFORMATION FOR ANY PURPOSE NOT LISTED BELOW, WITHOUT YOUR SPECIFIC WRITTEN AUTHORIZATION. ANY SPECIFIC WRITTEN AUTHORIZATION YOU PROVIDE MAY BE REVOKED AT ANY TIME BY WRITING TO US AT THE ADDRESS PROVIDED AT THE END OF THIS NOTICE. FOR TREATMENT: We may use your medical information to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, caregivers, or other people who are taking care of you. We may share medical information about you to other health care providers you designate to assist them in treating you. FOR PAYMENT: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information. FOR REMINDERS: We may call, email, or send you mail regarding appointments, annual check-ups, and reminders. YOUR INDIVIDUAL RIGHTS You have the right to: ✓ Look at or get copies of certain parts of your medical information. You must make your request in writing. ✓ Receive a list of all the times we or our business associates shared your medical information for purposes other than treatment, payment, and health care operations and other specified exceptions. ✓ Request that we communicate with you about your medical information by different means or at different locations. Your request that we communicate your medical information to you by different means or at different locations must be made in writing. ✓ Request that we change certain parts of your medical information. We may deny your request if we did not create the information you want changed or for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information. If you have any questions about this notice or if you think that we may have violated your privacy rights, please contact us at: Denver Regenerative Medicine | 455 N Sherman St Ste 450, Denver, CO 80203 Privacy Statement(Required) I acknowledge and agree to the aboveYour First and Last Name(Required)Privacy Statement Signature(Required)Tells Us About Your LifestyleAre You Experiencing Any Joint Pain? Yes No Please Describe The Kind Joint Pain and WhereDo you use (please select all that apply) Tobacco Caffeine Alcohol Recreational Drugs Exercise/Hobbies/Recreation:Have you been seen by a physician for the condition you are coming in for?(Required)Please ChooseYesNoAre your medical records available if requested?(Required)Please ChooseYesNoHow Do you Rate Your Overall General Health?(Required)ExcellentVery GoodAverageFairPoorDo you have any drug allergies?(Required)Please ChooseNoneYesIf selected "yes" please list (then click plus sign to add extras sections) Add RemovePersonal Health History (please check ALL that apply)(Required) chest pain heart failure murmur vascular disease blood clots fainting allergies lower extremity edema shortness of breath bronchitis asthma pneumonia gallstones lactose intolerance diarrhea constipation overactive bladder frequent urination diabetes painful urination prostate enlargement high blood pressure high cholesterol depression NONE OF THE ABOVE Other Your Current Primary PhysicianPlease list ALL medications and dosages: (include supplements, prescription, and over the counter medications)(Required)click plus sign on right to add more Add RemoveInsuranceOnly For Testosterone Therapy – otherwise not neededInsurance ProviderOnly For Testosterone Therapy – otherwise not neededInsurance IDOnly For Testosterone Therapy – otherwise not neededInsurance GroupOnly For Testosterone Therapy – otherwise not neededTreatmentsChoose Your Treatment(Required) Semaglutide treatment – $590 initial payment (one time fee, charged upon form processing) and $295/month (charged monthly for the duration of the contract) Tirzepatide treatment – $950 initial payment (one time fee, charged upon form processing) and $475/month (charged monthly for the duration of the contract). Testosterone Replacement Therapy (no labs) – $225 – Testosterone replacement therapy (includes medicine AND labs) Testosterone Replacement Therapy (with labs) – $193 – Testosterone replacement therapy (includes medicine, DOESN’T include labs) Peptide Treatment – $1 – Will be charged as a hold. Peptide treatment options to be discussed with your patient coordinator and pricing will be determined then. (Pricing Discussed Later) I authorize Denver Regenerative Medicine to charge my credit card the following below. Should our medical providers determine that the treatment you have selected is not clinically appropriate, Denver Regenerative Medicine will refund your payment in full.(Required) Subtotal Recurring Credit Card Payment AuthorizationCredit Card(Required) American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Security Code Cardholder Name Billing Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code ACKNOWLEDGEMENT AND LIABILITY RELEASE CLIENT ACKNOWLEDGEMENT AND LIABILITY RELEASE Treatment Liability Waiver I acknowledge that elective supplementation therapies, including, but not limited to Semaglutideand/or Tirzepatide Weight Management Treatment, may be considered medically unnecessary. Itmay or may not mitigate, alleviate, or cure the condition for which it has been prescribed. Thistreatment has been recommended to me in the belief that it is of potential benefit and its use will quiteprobably improve the condition for which I am under treatment for. Based on the risks and potentialbenefits of this proposed treatment, I have elected to receive this proposed treatment by providers andstaff at Denver Regenerative Medicine. I understand that I may suspend or terminate my treatment at anytime by informing my medicalprovider. I understand that I must give 30 days notice to suspend or cancel my recurring paymentsagreement. I understand that my final payment owed will be processed upon terminationand not on a future scheduled date. I assume full liability for any adverse effects that may result from the non-negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. Therefore, in consideration for any treatment received, I agree to unconditionally defend, hold harmlessand release from any and all liability the company and the individual that provided my treatment, theinsured, and any additional insured’s, as well as any officers, directors, or employees of the abovecompanies for any condition or result, known or unknown, that may arise as a consequence of anytreatment that I receive. I understand and agree that any legal action of any kind related to any treatment I receive will belimited to binding arbitration using a single arbitrator agreed to by both parties. By accepting below, I acknowledge and agree: I have carefully read the information on this page and understand its contents. CLIENT ACKNOWLEDGEMENT AND LIABILITY RELEASE(Required) I understand that the treatments I am receiving are elective and may not be medically necessary or guaranteed effective. I voluntarily consent to treatment and accept full responsibility for any non-negligent side effects. I release Denver Regenerative Medicine and its staff from any liability related to treatment outcomes. I understand I may stop treatment at any time, with 30 days’ notice required to cancel recurring payments. Any disputes will be resolved through binding arbitration.Recurring Payment Cancellation Policy(Required) I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Denver Regenerative Medicine in writing of any changes in my account information or termination of this authorization at least 30 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I acknowledge that the origination of Credit Card transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this Credit Card and will not dispute these scheduled transactions; so long as the transactions correspond to the terms indicated in this authorization form.Recurring CC Payment Authorization(Required) You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be provided to you and the charge will appear on your credit card statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.Signature(Required)I agree to the above statements and certify that information provided is correct
