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HGH a Sign Up Information

Last Updated:

6/22/2020

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Membership Emails

Below is a sample of the emails you can expect to receive when signed up to HGH a.

Emma, Still Considering Hormon...
Emma, a Special New Year's Ann...

Hi Emma,

I hope you are doing well and staying healthy through these unusual times. I am following up with you from a past inquiry that you made on our website.
At that time, you were interested in Hormone Replacement Therapy. If this is something you are still considering, I want you to know that getting started takes only 3 easy steps:

1) Medical History Form: Complete and submit the form on our website. https://www.kingsbergmedical.com/medical-history-form/

2) Blood work: This shows us a complete picture as to your hormone levels, overall health and why you might be experiencing the symptoms that you are. Should you need this service, we have pre-negotiated rates with our partner, LabCorp ($299). Or, we will also accept blood work completed with your physician, if less than 12 months old.

3) A physical exam: A simple wellness check from a walk-in clinic or your doctor. We will also accept an employment physical or sports physical.

Once we receive all of your information, your prescribing physician will review it and make a recommendation for you based on your deficiency levels.

I will contact you with the doctor's recommendations, and based on the prescribed medications, we will discuss the program and cost for your custom therapy.

Once you decide to pursue hormone replacement therapy, your prescriptions and supplies will be shipped directly to you at home for self-administration.

Please contact me with any questions that you might have, or to get started with a program at Kingsberg Medical. I will follow up with you soon and look forward to discussing the life--changing benefits of hormone replacement therapy.

Thank you,

Jodi Keene

Program Advisor

KINGSBERG MEDICAL

Email: JKeene@hgh1.com

Phone: (305) 306 - 0520

Fax: (954) 337-3779

WWW.HGH1.COM

Dear Emma,

This is Jodi Keene, your Clinical Advisor from Kingsberg Medical.
I am writing with some great news for you to start your New Year off right.

First of all, I am excited to tell you that we are now participating in Zoom for Healthcare, which means you can consult with one of our physicians about any of our services from the comfort and privacy of your home. With Zoom for Healthcare, we can even do your complete physical exam online!

As an added incentive to start a healthier 2021, we are offering a Special Discount on our Super Blood Panel. This blood test, which shows us a complete picture of your overall health and hormone levels, is normally $399 - but between now and the end of January, you will receive $100 off.

You can have this comprehensive test done by LabCorp - one of the most respected labs in the country - for the exceptionally low cost of $299.

But you must act now -- this is a limited time offer!
Please contact me if you would like to take advantage of this special discount or to schedule your Zoom appointment!

Jodi Keene

Program Advisor

KINGSBERG MEDICAL

Email: JKeene@hgh1.com

Phone: (305) 306 - 0520

Fax: (954) 337-3779

WWW.HGH1.COM

Raw Data Registration Structure Registration Form Text

Registration

Driver License:

First name

Last name

Title

Phone (home)

Phone (mobile)

Home address

City

State

Zipcode

Middle name

Gender

Gender:

Male

Vasectomy:

Yes

FAMILY HISTORYDoes an immediate family member currently have or ever had any of the following? If yes, please check below and explain in the provided field:Cardiovascular disease:

Yes

NoDiabetes, thyroid or other Endocrine Disorder:

Yes

NoHypertension:

Yes

NoLipid Disorder:

Yes

NoProstate cancer:

Yes

NoOther forms of cancer:

Yes

NoOther illnesses:

Yes

LIFESTYLE INFORMATIONDo you smoke?

Yes

Do you drink alcohol?

Yes

Do you take over the counter supplements?

Yes

Do you exercise regularly?

Yes

DIAGNOSED HISTORY OF DISEASEDo you currently have or ever had any of the following? If yes, please check below and explain in the provided field:Any known deficiency including minerals and electrolytes:

Yes

NoUse of medications (if yes, list medications below):

Yes

NoBlood disorders:

Yes

NoImmune disorders:

Yes

NoCancer:

Yes

NoChemical Dependency:

Yes

NoCarpal Tunnel syndrome:

Yes

NoLung disorder:

Yes

NoOrthopedic or muscle disorder including fracture or joint disorders:

Yes

NoHeart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack:

Yes

NoAllergies to Medications:

Yes

NoUpper respiratory:

Yes

NoEdema / excess fluid retention:

Yes

NoPoor wound healing:

Yes

NoEmotional disorders / depression:

Yes

NoRenal disease:

Yes

NoGenital - Urinary disorder:

Yes

NoHyperlipidemia:

Yes

NoHypertension:

Yes

NoNeurological disorders:

Yes

NoThyroid, Diabetes or other endocrine disorder including insulin resistance:

Yes

NoArthritis:

Yes

NoBursitis:

Yes

NoRheumatism:

Yes

NoSports Injury:

Yes

NoOther illnesses:

Yes

STEROIDSPrior history of Steroids or hormones?

Yes

NoPlease select:Test:

Yes

NoDeca:

Yes

NoWinstrol:

Yes

NoHGH:

Yes

NoThyroid:

Yes

NoOther:

Yes

NoEst:

Yes

NoPremarin:

Yes

NoProges:

Yes

NoProvera:

Yes

NoBirth Control:

Yes

Prior Medical Records / Labs?

Yes

Used estrogen-blocker?

Yes

NoQUESTIONS FOR TREATMENTProspective Patients: Please check the symptoms you hope to improve through hormone replacement therapy (HRT). Existing Patients: Please check the symptoms you have improved and hope to continue to improve through HRT. NATIONAL HRT AND ITS PHYSICIANS DO NOT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT. We do not treat bodybuilders or professional athletes. You must have a verified deficiency and medical need to qu

Yes

NoIncreasing fat deposits around the abdomen and/or thighs:

Yes

NoIncreasing mood swings:

Yes

NoIncreasing sagging muscles or breasts:

Yes

NoIncreasing wrinkles:

Yes

NoIncreasingly stressed:

Yes

NoDecreased desire and ability to exercise:

Yes

NoDecreased energy or endurance:

Yes

NoDecreased sense of well-being:

Yes

NoDecreasing memory:

Yes

NoDecreasing muscle strength:

Yes

NoDecreasing size of testicles:

Yes

NoProgressive osteoporosis, decreasing bone mass or stooped posture:

Yes

NoCold or heat intolerance:

Yes

NoCurrently Pregnant:

Yes

NoDepression:

Yes

NoDifficulty sleeping:

Yes

NoHeadaches / Migraines:

Yes

NoHot flashes:

Yes

NoLoss of concentration, sociability, activity:

Yes

NoLoss of interest in sex:

Yes

NoMuscle loss:

Yes

NoSagging, loose or thin skin:

Yes

NoSore Muscles, join pain(s) or swelling:

Yes

NoThinning or loss of hair:

Yes

NoUrogenital atrophy:

Yes

NoWeight loss - Unexplained:

Yes

NoOther:

Yes

I understand that the medications i have purchased are prescribed for me on diagnosis derived from my submitted medical history, blood and lab report. and physi

SECTION 3: Signature3 of 3Patient Authorization and AgreementThe undersigned Patient ("Patient") authorizes and instructs National HRT ("National HRT") to provide the 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"). Patient submits with this Agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond truthfully, accurately

I will immediately report any adverse side effects related to the use of my medication to National HRT and discountinue use until advised to resume usage by Nat

I will immediately report any adverse side effects related to the use of my medication to National HRT and discountinue use until advised to resume usage by National HRT.

I will safeguard my medications from loss or theft.

I understand that National HRT does not cooperate with any insurance companies. If any part of my prescription from National HRT's doctors is to be picked up at a local pharmacy,

I understand that National HRT does not cooperate with any insurance companies. If any part of my prescription from National HRT's doctors is to be picked up at a local pharmacy, I agree to pay cash for that medication. I will not request that it be processed through my insurance.

I will not sell, share or trade my medications for money, goods or services.

I agree that I will use my medications at the prescribed rate and dosage, and I will keep the medications in its respective labeled container.

I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my curr

I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is illegal to do so.

I attest I am not seeking medical treatment for body enhancement, body building or performance enhancement or cosmetic enhancement of any kind.

I am seeking this treatment for legitimate medical purposes.

I have read the text above, and I agree to the terms and conditions disclosed herein.

Data Name	Data Type	Options
Driver License:	Text Box
First name	Text Box
Last name	Text Box
Title	Text Box
Email	Text Box
Phone (home)	Text Box
Phone (mobile)	Text Box
Home address	Text Box
City	Text Box
State	Text Box
Zipcode	Text Box
Middle name	Text Box
Gender	Text Box
	option	Gender:
	option	Male
	option	Vasectomy:
	option	Yes
	option	FAMILY HISTORYDoes an immediate family member currently have or ever had any of the following? If yes, please check below and explain in the provided field:Cardiovascular disease:
	option	Yes
	option	NoDiabetes, thyroid or other Endocrine Disorder:
	option	Yes
	option	NoHypertension:
	option	Yes
	option	NoLipid Disorder:
	option	Yes
	option	NoProstate cancer:
	option	Yes
	option	NoOther forms of cancer:
	option	Yes
	option	NoOther illnesses:
	option	Yes
	option	LIFESTYLE INFORMATIONDo you smoke?
	option	Yes
	option	Do you drink alcohol?
	option	Yes
	option	Do you take over the counter supplements?
	option	Yes
	option	Do you exercise regularly?
	option	Yes
	option	DIAGNOSED HISTORY OF DISEASEDo you currently have or ever had any of the following? If yes, please check below and explain in the provided field:Any known deficiency including minerals and electrolytes:
	option	Yes
	option	NoUse of medications (if yes, list medications below):
	option	Yes
	option	NoBlood disorders:
	option	Yes
	option	NoImmune disorders:
	option	Yes
	option	NoCancer:
	option	Yes
	option	NoChemical Dependency:
	option	Yes
	option	NoCarpal Tunnel syndrome:
	option	Yes
	option	NoLung disorder:
	option	Yes
	option	NoOrthopedic or muscle disorder including fracture or joint disorders:
	option	Yes
	option	NoHeart disease including Atherosclerosis, Angina, Heart Failure, Heart Attack:
	option	Yes
	option	NoAllergies to Medications:
	option	Yes
	option	NoUpper respiratory:
	option	Yes
	option	NoEdema / excess fluid retention:
	option	Yes
	option	NoPoor wound healing:
	option	Yes
	option	NoEmotional disorders / depression:
	option	Yes
	option	NoRenal disease:
	option	Yes
	option	NoGenital - Urinary disorder:
	option	Yes
	option	NoHyperlipidemia:
	option	Yes
	option	NoHypertension:
	option	Yes
	option	NoNeurological disorders:
	option	Yes
	option	NoThyroid, Diabetes or other endocrine disorder including insulin resistance:
	option	Yes
	option	NoArthritis:
	option	Yes
	option	NoBursitis:
	option	Yes
	option	NoRheumatism:
	option	Yes
	option	NoSports Injury:
	option	Yes
	option	NoOther illnesses:
	option	Yes
	option	STEROIDSPrior history of Steroids or hormones?
	option	Yes
	option	NoPlease select:Test:
	option	Yes
	option	NoDeca:
	option	Yes
	option	NoWinstrol:
	option	Yes
	option	NoHGH:
	option	Yes
	option	NoThyroid:
	option	Yes
	option	NoOther:
	option	Yes
	option	NoEst:
	option	Yes
	option	NoPremarin:
	option	Yes
	option	NoProges:
	option	Yes
	option	NoProvera:
	option	Yes
	option	NoBirth Control:
	option	Yes
	option	Prior Medical Records / Labs?
	option	Yes
	option	Used estrogen-blocker?
	option	Yes
	option	NoQUESTIONS FOR TREATMENTProspective Patients: Please check the symptoms you hope to improve through hormone replacement therapy (HRT). Existing Patients: Please check the symptoms you have improved and hope to continue to improve through HRT. NATIONAL HRT AND ITS PHYSICIANS DO NOT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT. We do not treat bodybuilders or professional athletes. You must have a verified deficiency and medical need to qu
	option	Yes
	option	NoIncreasing fat deposits around the abdomen and/or thighs:
	option	Yes
	option	NoIncreasing mood swings:
	option	Yes
	option	NoIncreasing sagging muscles or breasts:
	option	Yes
	option	NoIncreasing wrinkles:
	option	Yes
	option	NoIncreasingly stressed:
	option	Yes
	option	NoDecreased desire and ability to exercise:
	option	Yes
	option	NoDecreased energy or endurance:
	option	Yes
	option	NoDecreased sense of well-being:
	option	Yes
	option	NoDecreasing memory:
	option	Yes
	option	NoDecreasing muscle strength:
	option	Yes
	option	NoDecreasing size of testicles:
	option	Yes
	option	NoProgressive osteoporosis, decreasing bone mass or stooped posture:
	option	Yes
	option	NoCold or heat intolerance:
	option	Yes
	option	NoCurrently Pregnant:
	option	Yes
	option	NoDepression:
	option	Yes
	option	NoDifficulty sleeping:
	option	Yes
	option	NoHeadaches / Migraines:
	option	Yes
	option	NoHot flashes:
	option	Yes
	option	NoLoss of concentration, sociability, activity:
	option	Yes
	option	NoLoss of interest in sex:
	option	Yes
	option	NoMuscle loss:
	option	Yes
	option	NoSagging, loose or thin skin:
	option	Yes
	option	NoSore Muscles, join pain(s) or swelling:
	option	Yes
	option	NoThinning or loss of hair:
	option	Yes
	option	NoUrogenital atrophy:
	option	Yes
	option	NoWeight loss - Unexplained:
	option	Yes
	option	NoOther:
	option	Yes
I understand that the medications i have purchased are prescribed for me on diagnosis derived from my submitted medical history, blood and lab report. and physi	checklist	SECTION 3: Signature3 of 3Patient Authorization and AgreementThe undersigned Patient ("Patient") authorizes and instructs National HRT ("National HRT") to provide the 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"). Patient submits with this Agreement an accurately completed Medical History Form ("MHF"). Patient agrees to respond truthfully, accurately
I will immediately report any adverse side effects related to the use of my medication to National HRT and discountinue use until advised to resume usage by Nat	checklist	I will immediately report any adverse side effects related to the use of my medication to National HRT and discountinue use until advised to resume usage by National HRT.
I will safeguard my medications from loss or theft.	checklist	I will safeguard my medications from loss or theft.
I understand that National HRT does not cooperate with any insurance companies. If any part of my prescription from National HRT's doctors is to be picked up at a local pharmacy,	checklist	I understand that National HRT does not cooperate with any insurance companies. If any part of my prescription from National HRT's doctors is to be picked up at a local pharmacy, I agree to pay cash for that medication. I will not request that it be processed through my insurance.
I will not sell, share or trade my medications for money, goods or services.	checklist	I will not sell, share or trade my medications for money, goods or services.
I agree that I will use my medications at the prescribed rate and dosage, and I will keep the medications in its respective labeled container.	checklist	I agree that I will use my medications at the prescribed rate and dosage, and I will keep the medications in its respective labeled container.
I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my curr	checklist	I will not attempt to obtain "scheduled" hormone replacement therapy medications illegally or from any other health care practitioner without disclosing my current medication usage. I understand that it is illegal to do so.
I attest I am not seeking medical treatment for body enhancement, body building or performance enhancement or cosmetic enhancement of any kind.	checklist	I attest I am not seeking medical treatment for body enhancement, body building or performance enhancement or cosmetic enhancement of any kind.
I am seeking this treatment for legitimate medical purposes.	checklist	I am seeking this treatment for legitimate medical purposes.
I have read the text above, and I agree to the terms and conditions disclosed herein.	checklist	I have read the text above, and I agree to the terms and conditions disclosed herein.