I hereby release, the Physician, his Practitioners, Wellness and Weight Loss, their employees, and their partners from any and ALL liability whatsoever associated with or connected to my Human Identical Hormone Therapy (also referred to herein as Bio-Identical Hormone Therapy) and/or the use of these hormones. I acknowledge that I am legally responsible and aware of the potential side-effects associated with this therapy. I understand that no Doctor, Nurse Pharmacist, or administrative personnel can guarantee that Human-Identical Hormones will provide the results I seek. I am participating in this program by my own choice, and I assume any and ALL responsibility for said outcomes. I fully understand that it is solely my responsibility to have an annual physical exam including PSA, Digital Rectal exam, and/or any other lab/diagnostic testing necessary to insure my continued health and eligibility to continue on this therapy. I have been advised of any and all possible risks associated with Human-Identical Hormones including a possible increase in the chance of cardiovascular events such as Heart Attack, Stroke, Blood Clots, Pulmonary Embolus, Breast Cancer, Uterine Cancer, persistent vegetative state (coma) or even death that may possibly be related with or to my use of Human Identical Hormones.

BY CHECKING THE BOX BELOW I CONSIDER THE ABOVE DOCUMENT TO BE LEGALLY SIGNED BY ME AND I AM BOUND BY ALL STATEMENT THEREIN....