TESTOSTERONE MEDICATION USE AGREEMENTTestosterone Medication Use Agreement • June 10th, 2020 • Colorado
, 2020, by and between (the “Patient”), and Revive MD, LLC a Colorado Limited Liability Company (“Revive MD”). The Patient hereby agrees and expressly authorizes Revive MD to secure a medical laboratory, physician/medical doctor (“Treating Physician”) and dispensing pharmacy (collectively “ Medical Providers”) to provide the Patient diagnostic testing, medical care and prescribed pharmaceuticals based on the completed and accurate medical history form (“Medical History Form”) provided by the Patient, and any laboratory diagnostic tests obtained through Revive MD, pursuant to and subject to the terms and conditions of this Agreement. The Patient understands that the Medical History Form becomes the property of Revive MD and the Patient will have continuing access and the right to copy and retain all portions of the medical record, subject to applicable law.
