Add-On Treatment

Name *

First

Last

What medication(s)are we currently prescribing you ? *

What new medication do you want to add-on as an additional treatment ? *

Why are you requesting this additional treatment ? *

Email *

*You will receive an email confirmation with invoice.

Please Read & Sign Below *

I am requesting this medication because I believe I will benefit from it. I have done my research on this medication and I am fully aware of the benefits, risks, and potential side effects. I have also read the manufacturer's recommended dosing regimen. I agree to follow up with my primary care physician as recommended and submit routine blood work when scheduled. I promise to consistently maintain a healthy diet and regular exercise routine. I would like a Superior Genetix Health & Wellness, Inc Physician to review my medical chart and approve me for this additional treatment. I certify that I am healthy enough to use this medication, and I have had no adverse side effects with any other medication prescribed to me by Superior Genetix Health & Wellness, Inc.

Date / Time *

Signature *

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