Disclamer

The Nature of the Treatment

I hereby give my consent to evaluation and treatment by Rank One, and healthcare practitioners in partnership with Rank One of the following specified condition(s):

I agree to the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or drugs designed to alter hormone levels, all as appropriate to my specific diagnosis, particular condition and treatment objectives.

Alternative Treatment Methods and Their General Nature

The reasonable alternatives to this treatment have been explained to me and they include:

1. Leaving the hormone levels as they are.

2. Treating age related diseases as they appear.

3. Using pharmaceutical agents that are not bioidentical in nature (synthetics)

I understand the foregoing alternatives and am choosing to consent to the treatment plan prepared for me by Rank One and the healthcare professionals and in partnership with Rank One to address the condition(s) indicated above.

The General Nature and Extent of Treatment- Related Risks

Women: I understand that the possible side effects for women on estrogen, progesterone and/or testosterone may include breast swelling and/or discomfort, fluid retention, dizziness, thickening of the lining of the uterus (break-through bleeding), acne, unwanted hair growth, headaches, slight deepening of the voice, slight enlargement of the clitoris, potential increased risk of blood clots, and worsening of (1) ovarian cysts, (2) uterine fibroids, (3) endometriosis, and (4) fibrocystic disease.

Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to -skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co-habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Men: I understand that the possible side effects for men on testosterone replacement are acne, persistent erections, unwanted hair growth/loss, enlargement of the prostate, enlargement of breast tissue (we will monitor and treat estrogen levels), minor testicular atrophy, salt retention, increase in blood pressure, decreased sperm count, an increase in the number of red blood cells (erythrocytosis) with corresponding increase in hematocrit and/or hemoglobin (your blood will be monitored for this). Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to-skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co-habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Safety of Hormone Replacement

Although, in my physician’s opinion, the majority of data points toward safety, there remains controversy regarding the correlation between the use of bioidentical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol/estradiol may be protective against breast cancer.

I understand that careful surveillance and close monitoring are requirements of all patients to minimize any possible risk. I understand that Rank One or its partners will monitor my hormone levels and various other laboratory values as they pertain to my treatment goals. However, I also understand that an integral part of health maintenance is obtaining and remaining up to date with age appropriate screening tests aimed at early detection of life-threatening diseases.

Informed Consent to Treat

Rank One Medical, LLC (“Rank One”)

The Nature of the Treatment

I hereby give my consent to evaluation and treatment by Rank One, and healthcare practitioners in partnership with Rank One of the following specified condition(s):

I agree to the administration of hormone replacement therapy and/or nutritional supplements, including vitamins, minerals and anti-oxidants and/or drugs designed to alter hormone levels, all as appropriate to my specific diagnosis, particular condition and treatment objectives.

Alternative Treatment Methods and Their General Nature

The reasonable alternatives to this treatment have been explained to me and they include:

1. Leaving the hormone levels as they are.

2. Treating age related diseases as they appear.

3. Using pharmaceutical agents that are not bioidentical in nature (synthetics)

I understand the foregoing alternatives and am choosing to consent to the treatment plan prepared for me by Rank One and the healthcare professionals and in partnership with Rank One to address the condition(s) indicated above.

The General Nature and Extent of Treatment- Related Risks

Women: I understand that the possible side effects for women on estrogen, progesterone and/or testosterone may include breast swelling and/or discomfort, fluid retention, dizziness, thickening of the lining of the uterus (break-through bleeding), acne, unwanted hair growth, headaches, slight deepening of the voice, slight enlargement of the clitoris, potential increased risk of blood clots, and worsening of (1) ovarian cysts, (2) uterine fibroids, (3) endometriosis, and (4) fibrocystic disease.

Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to -skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co-habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Men: I understand that the possible side effects for men on testosterone replacement are acne, persistent erections, unwanted hair growth/loss, enlargement of the prostate, enlargement of breast tissue (we will monitor and treat estrogen levels), minor testicular atrophy, salt retention, increase in blood pressure, decreased sperm count, an increase in the number of red blood cells (erythrocytosis) with corresponding increase in hematocrit and/or hemoglobin (your blood will be monitored for this). Many of these effects can be temporary as your body adjusts to restoration. Some of these potential side effects can often be addressed by adjusting hormone levels or prescribing simple remedies. I also understand that if topical hormone replacement treatment (cream, gel, etc) is prescribed for me that I should take extreme care to avoid any collateral exposure via direct skin-to-skin contact with the application site or exposure to contaminated bed linens, clothes, etc. for any children, pets, co-habitants of the home, or anyone else whom may come into contact with the hormonal treatment cream/gel. I have been informed that accidental collateral exposure may significantly impact the hormone levels of those affected.

Safety of Hormone Replacement

Although, in my physician’s opinion, the majority of data points toward safety, there remains controversy regarding the correlation between the use of bioidentical hormone therapy and cancer. Recent data demonstrates that natural progesterone and estriol/estradiol may be protective against breast cancer.

I understand that careful surveillance and close monitoring are requirements of all patients to minimize any possible risk. I understand that Rank One or its partners will monitor my hormone levels and various other laboratory values as they pertain to my treatment goals. However, I also understand that an integral part of health maintenance is obtaining and remaining up to date with age appropriate screening tests aimed at early detection of life-threatening diseases.Male patients:(IF APPLICABLE)/(IF NOT PLEASE WRITE “NOT APPLICABLE) I,_________________, agree to obtain and remain up to date on all age-appropriate screenings including, but not limited to, colonoscopy, PSA and DRE (digital rectal exam), cardiac screenings as necessary (stress test, etc.).

I agree to obtain these screenings through the appropriate physician(s) (PCP, cardiologist, urologist, etc) and will not hold Rank One or Evan Sheets or healthcare practitioners responsible or liable for performing these screenings or treating/managing any abnormal findings relating to these screenings. I acknowledge that Rank One would like to be supplied with copies of my most current and any future screening results and that, if I do not have them at my initial visit, by signing this consent I express my desire to initiate my treatment at Rank One and give permission to Rank One and its partners, to commence treatment without first knowing the results of or reviewing said screenings. In doing so, I release Rank One of any claims of liability for prostate cancer, breast cancer, testicular cancer, and/or colon cancer. Further, I agree to immediately notify Rank One of any abnormal findings on above-noted screenings and supply a copy of any applicable records for their review.Female patients: (IF APPLICABLE)/(IF NOT PLEASE WRITE “NOT APPLICABLE) I,_________________ , agree to obtain and remain up to date on all age-appropriate screenings including, but not limited to, colonoscopy, PAP smear and pelvic exam, Mammogram and breast exam, DEXA scan, and cardiac screenings as necessary (stress test, etc.).

I agree to obtain these screenings through the appropriate physician(s) (PCP, OBGYN, cardiologist, etc) and will not hold Rank One’s staff, Evan Sheets, or healthcare practitioners in partnership with Rank One responsible or liable for performing these screenings or treating/managing any abnormal findings relating to these screenings. I acknowledge that Rank One would like to be supplied with copies of my most current and any future screening results and that, if I do not have them at my initial visit, by signing this consent I express my desire to initiate my treatment at Rank One and give permission to Rank One and providers in partnership with Rank One to commence treatment without first knowing the results of or reviewing said screenings. In doing so, I release Rank One and providers in partnership with Rank One of any claims of liability for breast cancer, cervical cancer, ovarian cancer, uterine cancer, and/or colon cancer. Further, I agree to immediately notify Alpha One, of any abnormal findings on above-noted screenings and supply a copy of any applicable records for their review.Female patients (IF APPLICABLE)/(IF NOT PLEASE WRITE “NOT APPLICABLE”): I,_______________, understand that it has been more than one year since my last mammogram.

The health professionals affiliated or in partnership with Rank One strongly recommend annual mammograms because we consider these vital in the early detection of breast cancer.

I agree and understand that it is not the responsibility of Rank One or its partners, to perform my recommended Mammogram screening and breast exam.

I also understand that certain types of breast cancer, once present, may be stimulated by estrogen including my own body’s estrogen, and taking estrogen therapy with a present/active breast cancer may worsen the chances of survival.

I also understand there are possible benefits associated with this therapy but that no guarantee has been made to me regarding outcomes of this treatment. I also understand that the benefits derived from antioxidant therapy and vitamin therapy will cease and those derived from hormone therapy and drugs that alter hormone levels will reverse if the therapy is discontinued.

I also understand that if I am female and become pregnant, I should stop the entire treatment protocol immediately and notify my physician (see separate disclaimer and warning). I understand that this hormone therapy is not for the purpose of preventing pregnancy, and that if I become pregnant on this therapy it could present risk to the fetus (unborn child).

My Obligations and Representations

Any questions I have regarding this treatment have been answered to my satisfaction. I understand that I will be responsible for administering the hormones prescribed to me. I will comply with the recommended dose and methods of administration. I also agree to participate in the initial and subsequent hormone testing, as required to safely monitor and treat my hormone levels.

I certify that I am under the regular care of another physician (Primary Care Physician, OBGYN, Urologist, etc.) for all other medical conditions. I will consult my physician(s) for any other medical services I may require. I understand that this is a specialized practice. I also understand that I will continue under the care of my other physician(s) for any on-going medical condition as well as for any medical consultation that I may need.

Being aware of all aforementioned facts and notices in this document, and after weighing potential risks vs potential benefits, I elect to commence the aforesaid treatment with Rank One and its partners and assume full liability for any adverse effects that may result from 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 therapy, except as that claim pertains to grossly negligent administration of the therapy.

I fully understand the nature and purpose of portions of the aforementioned treatment may be considered experimental because of the lack of adequate scientific evidence or peer-reviewed publications supporting the underlying premise of bioidentical hormone replacement therapy and that such therapy might even be considered by some medical professionals to be medically unnecessary because it is not aimed at treating a particular disease.

I understand that I may suspend or terminate treatment at any time and hereby agree to immediately notify the physician of any desire to suspend or terminate this treatment so that such suspension or termination may be done safely.

Consent

I hereby authorize my physician to evaluate and treat the conditions I specified on the above pages (this is a 4-page document). I understand my physician may be assisted by other health professionals, as necessary, and agree to their participation in my care as it relates to the evaluation and treatment of the conditions this Consent to Treat covers. I certify that I am 18 years of age or older, am competent to sign this Consent to Treat and have done so of my own free will.

I understand that Rank One and the Doctors who are in partnership with Rank One are not Primary Care Physicians. Rank One and its affiliated Doctors will not provide me primary care and cannot take the place of a primary care physician (PCP). If I do not have a PCP I am encouraged to establish a relationship with a PCP and communicate my treatment received by Rank One or its partners to my PCP.

Medical Consent and Authorization for Electronic Communication (Email)

Rank One Medical, LLC

E-mail communication provides for a fast and easy way to communicate with your healthcare provider for those issues that are non-emergent, non-urgent or non-critical. It is not a replacement for the interpersonal contact that is the very basis of the patient-healthcare provider relationship; rather it can support and strengthen an already established relationship.

The following summarizes the information you need to determine whether you wish to supplement your healthcare experience at our practice by electronically communicating with staff members.

General Considerations

E-mail communication will be considered and treated with the same degree of privacy and confidentiality as written medical records.

Standard e-mail services, such as Gmail, AOL, Yahoo, and Hotmail are not secure. This means that the e-mail messages are not encrypted and can be intercepted and read by unauthorized individuals.

Transmitting e-mail that contains protected health information through an e-mail system that is not encrypted does not meet the security guidelines as required by the Health Information Protection and Accountability Act (HIPAA).

Your E-mail address will not be used for external marketing purposes without your permission. You may receive a group mailing from the practice, however, the recipients e-mail addresses will be hidden.

Provider Responsibilities

The Provider will attempt to electronically confirm your e-mail address by requesting a return response to all email messages.

Your provider may route your e-mail messages to other members of the staff for informational purposes or for expediting a response.

Designated staff may receive and read your e-mail.

The provider will make every attempt to respond to your email message within 1 business days. If you do not receive a response from the provider within 1 business days, please contact the office.

Copies of e-mails sent and received from and to you will be incorporated into your medical record. You

are advised to retain all electronic correspondence for your own files.

Patient Responsibilities

E-mail messages should not be used for emergencies or time sensitive situations. In the event of a medical emergency, you should contact 911. For emergent or time sensitive situations, you should contact your healthcare provider through the office.

E-mail messages should be concise. Please arrange for an office appointment if the issue is too complex or sensitive to discuss via e-mail.

Please key in your full name and the topic, i.e., medication question, in the subject line. This will serve to

identify you as the sender of the e-mail.

Please acknowledge that you received and read the provider’s message by return e-mail to the provider

ADDING Rank One TO YOUR APPROVED SENDERS LIST

Due to the importance of using email we want to make sure that every patient who provides us with their email address is able to receive our communication. In order to protect your privacy many email providers have strict rules which filter any incoming emails containing large attachments or specific content. Health

information such as blood test results are sent by email in an attachment which can be blocked by your email provider’s security filter which is designed to protect you from receiving anything which might harm your computer. Unfortunately, this security feature can also block legitimate emails unless the senders address is approved by the recipient. If you would like to use email as a means of communication, please be sure to unblock emails from defymedical.com. Depending on your email service provider, there are ways to unblock email addresses and approve the sender so that you may receive emails. Also be sure to check your SPAM or junk email inboxes for emails sent by Rank One.

Contact Us

Rank One Medical is an innovative and personalized approach to male and female performance therapy with an emphasis on concierge service and optimization of treatment. Rank One Medical will operate implementing the Telemedicine platform.

Facebook-f Instagram

Founded by U.S.A. Military Veterans