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Become a Patient

  • Patient Information and Medical History Form
  • Basic Examination i.e. Height, Weight, BP, Pulse
  • Product Usage i.e. Tobacco, Alcohol, Caffeine
  • Allergies
  • Over The Counter Medication
  • Past/Present Medical Conditions
  • Current Medication/Vitamins/Supplements
  • Family History (Father,Mother,Siblings only)
  • Woman Only
  • Weight-Loss Consumer Bill of Rights 501.0575
  • (1) The Weight-Loss Consumer Bill of Rights shall consist of the following provisions:

    • (A) Warning: rapid weight loss may cause serious health problems. Rapid weight loss is weight loss of more than 1 1⁄2 to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in a weight loss program.
    • (B) Consult your personal physician before starting any weight-loss program.
    • (C) Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss.
    • (D) Qualifications of this provider are available upon request.
    • (E) You have a right to:
      • (1) Ask questions about the potential health risks of this program and its nutritional content, psychological support and educational components.
      • (2) Receive an itemized statement of the actual or estimated price of the weight loss program, including extra products, services, supplements, examinations, and laboratory tests.
      • (3) Know the actual or estimated duration of the program
      • (4) Know the name, address, and qualifications of the physician, dietician or nutritionist who has reviewed and approved the weight- loss program according to 468.505(1)(i). Florida Statutes.

    Nu Image Medical is a licensed non-diagnostic preventative health care provider. Our doctors and medical staff directly prescribe all required tests and review and confirm all test results. We may also perform physical exams, consult with primary physicians, and validate and verify submitted medical information. Patients who are found to have signs and symptoms of a legitimate medical and/or health condition are referred to a medical specialist in that field for diagnosis and treatment in a specialized and monitored program. Nu Image Medical reserves the right to recommend and use internal and/or external medical specialists for any a patient and all patient information will be protected under all HIPPA laws and regulations. Nu Image Medical is not an internet pharmacy and does not dispense, ship, or distribute medications from our facilities or web sites. Any and all medication prescribed by our doctors and/or associated medical associates for medical treatment will be dispensed from a US FDA approved pharmacy. All patients are required to fulfill and follow all of the medical instructions and procedures prescribed by doctors and contact us immediately if they have any problems, questions, or concerns. Patients whom are found to have submitted fraudulent information will be terminated from any health program offered by Nu Image Medical or any of its affiliates. Any medication prescribed is only for the use of the patient and is not to be transferred, distributed, modified, or used by any other party.

    “Off Label” Use of HCG

    I understand that this therapy includes “off-label” use of the FDA approved medication HCG Human Chorionic Gonadotropin. I understand that this medication is FDA approved for other medical treatment modalities and has not been approved for the purpose of weight loss. (“Off-label” use means the use of FDA approved drugs for purposes other than those for which the FDA has approved them.) “Off-label” prescribing is a legal and common practice by physicians in the United States.

    Statement from the FDA

    I have been notified that since 1975, the FDA has required labeling and advertising of HCG to state: “HCG has not been demonstrated to be an effective adjunctive therapy in the treatment of obesity. There is no substantial evidence that it increases weight loss beyond that resulting from caloric restriction, that it causes a more attractive or "normal" distribution of fat, or that it decreases the hunger and discomfort associated with calorie-restricted diets.”

    I have read and understand above acknowledgments.

  • Patient authorization and consent
  • In consideration of instructs from Nu Image Medical, Inc. (“Nu Image Medical”) providing the undersigned patient (“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”). With this agreement, Patient submits with this agreement an accurately completed Medical History Form (“MHF”). Patient agrees to respond to truthfully, accurately and completely in completing the MHF or any agent sent by Nu Image Medical to complete the form and acknowledges that failure to provide truthful, accurate and complete information on the MHF or to Nu Image Medical or the physicians referred by Nu Image Medical could result in inappropriate treatment.

    Patient authorizes Nu Image Medical to obtain on my behalf medical laboratories, diagnostic testing, physicians and dispensing pharmacies. In addition, Patient authorizes and instructs Nu Image Medical and physicians referred by Nu Image Medical (“Physicians”) and dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals based on the MHF, laboratory diagnostic tests, and other information submitted to Nu Image Medical under this agreement. Patient agrees to present photo identification upon any blood testing pursuant to a Nu Image Medical or Physician test requisition.

    Patient acknowledges that therapies and laboratory and diagnostic testing services supplied or obtained by Nu Image Medical and medical services provided to me by Physicians, are not covered or reimbursed by Medicare or other insurance.

    Patient acknowledges that Nu Image Medical’s employees and agents are not licensed physicians and that Physicians obtained on my behalf by Nu Image Medical are independent contractors, which will be compensated by Patient with funds provided to Nu Image Medical. Patient acknowledges that Nu Image Medical does not practice medicine and that Nu Image Medical is a medical management, administrative, and referral service and does not direct, control, or influence the treatment decisions made by Physician. I further understand and agree that Nu Image Medical and Physicians are rendering the medical care, services and treatment and that Nu Image Medical is instructed and authorized to arrange for the prescribed pharmaceuticals to be dispensed and sent to me by any pharmacy in my country of residence.

    Patient covenants and agrees to comply with the method of instructions, treatment and dosage schedules prescribed by the Physician, to immediately cease any medical treatment prescribed by the Physician in the event of any adverse reaction or side effect arising from prescribed treatment, and to immediately provide Nu Image Medical and Physician with written notice via fax to (888) 831-4818 of any such adverse reaction or side effect. I further acknowledge and agree that Nu Image Medical is not liable for any negligent act or omission of the Physician. Patient acknowledges that diagnosis and treatment may involve risk of injury, and that Nu Image Medical and Physician have made no guarantees or warranties with respect to the above-described diagnostic testing, analysis of test results, examination of medical history or hormone treatment. Patient acknowledges that the hormone blood level objective sought as a result of the Patient’s hormone replacement therapy, as prescribed by Physician, may be at the highest level of a standard reference range for Patient’s age and sex, or, in some cases, above such range, to the level of a younger person, and that such range is experimental and may not render any benefits, but may result in unknown, adverse results. Patient is aware of the nature, risk, and possible alternative methods of treatment, possible consequences, and possible complications involved in such hormone replacement treatment. Patient acknowledges that recombination human growth hormone replacement therapy involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain a desired objective of medical treatment. Nonetheless, Patient consents to such care and treatment, and executes this Agreement with a complete, informed understanding of such hormone replacement therapy for the purpose of authorizing Physician to administer such treatment to relieve body ailments and attempt to enhance Patient’s physical condition and health. Patient further acknowledges that the methods of medical treatment offered by Nu Image Medical and Physician are not accompanied by any claims, guarantees, promises or warranties.

    It is fully agreed and understood by the patient that products purchased from Nu Image Medical require a medical prescription and as such are NOT returnable or refundable under any circumstances under both Federal and/or State laws. It is unlawful for a pharmacy to accept the return of prescription medications once they have left the control of the pharmacy.

    Patient is freely seeking medical consultation via the Internet or direct contact and acknowledges and consents to Physician reviewing Patient’s medical history without having the opportunity to conduct an in-person physical examination. Patient solicits Nu Image Medical for a specific prescription medication to treat an already-identified medical or cosmetic condition. Patient acknowledges that Physician may not be licensed to practice medicine in the Patient’s state or country of residence. Further, Patient agrees that Physician’s consultations, diagnoses, and treatments will be deemed to have occurred in Florida, where Physician is licensed to practice medicine. Patient represents that he or she is under the care of a primary care physician and that physicians will not rely or substitute the advice of physician should it conflict with the advice given to me by patient’s primary care physician. Before taking any medication prescribed by physician, patient agrees to have a comprehensive physical examination by his or her primary care physician. Patient agrees to notify his or her primary care physician and advise such physician that the patient isundergoing hormone replacement therapy.

    Patient acknowledges that under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. PHYSICIAN HAS DECIDED NOT TO CARRY MEDICAL MALPRACTICE INSURANCE. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against noninsured physicians who fail to satisfy adverse judgments arising from claims of medical malpractice. This notice is provided pursuant to Florida law.

    Patient acknowledges and agrees that Nu Image Medical is not responsible for the negligent or intentional acts or omissions of any health care provider or supplier that Patient is referred or for any action or inaction taken by Patient, that the total liability of Nu Image Medical, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through Nu Image Medical, Physicians or Pharmacies, and the Nu Image Medical and Physicians will not be liable for any direct, indirect, special, incidental, consequential, or punitive damages. During Patients relationship with Nu Image Medical and Physician, Nu Image Medical and Physician will convey to Patient a range of proprietary business information, including, confidential disclosures and trade secrets business practices and Nu Image Medical’s customers and suppliers (“Confidential Information”). No matter how received by the Patient during the parties’ relationship, Patient agrees that Confidential Information is confidential, proprietary and uniquely valuable to Nu Image Medical’s and gravely affects the conduct of business of Nu Image Medical and Nu Image Medical’s goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any Confidential Information or take any action that may result in disclosure of Confidential Information to any third party person, firm, or business. Patient agrees that if the terms of this paragraph are breached, Nu Image Medical shall be conclusively deemed to be irreparably injured and shall be entitled to an injunction restraining Patient from disclosing any Confidential Information and to liquidated damages. Patient agrees that the amount of Nu Image Medical’s actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and Patient agrees that such liquidated damages are not a penalty.

    Based on the above-understanding, Patient agrees to release Nu Image Medical, its officers, directors, employees, agents and shareholders, and Physician from any and all liability associated with or arising from the Physician’s consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physician’s consultation.

    This Agreement shall be governed, construed and enforced in accordance with the laws of the State of Florida, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in the Hillsborough County, Florida and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action or other proceeding arising out of, in connection with or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys’ fees and legal assistants’ fees.

    This Agreement contains the entire understanding of the parties and supersedes and merges all prior and contemporaneous agreements and discussions between the parties. Any and all representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void, and of no effect.

    If any provision of this Agreement or the application thereof to any person or circumstances is invalid or unenforceable in any jurisdiction, the remainder hereof, and all application of such provision to such person or circumstances in any other jurisdiction, shall not be effected thereby, and to this end the provisions of this Agreement shall be severable.

    Patient covenants and agrees to indemnify, defend, protect, and hold harmless, and Physician and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates (“Indemnified Parties”) from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, directly or indirectly, Nu Image Medical and/or Physician’s rendering medical care services, advice and/or treatment, Patient’s failure to disclose all relevant information regarding Patient’s medical and physical condition, acts or omissions of Nu Image Medical or Physician, harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by Nu Image Medical or Physician. Patient is aware of potential side effects associated with the above-described treatment, accepts all risks involved in taking medication and will not seek indemnification or damages from the Indemnified Parties there from.

The HCG Diet Program

Contact Us

Health & Aesthetics
3783 Georgetown Road NW
Cleveland, TN 37312