Examining Physician’s Physical Examination Acknowledgement Form

Patient Name _____________________________________________________________________________ SSN _________ -_________-___________

Address _______________________________________________________________________________ Phone ________________________________

City ________________________________________________ State __________ zip _______________ Medical Insurer __________________________

Physical Exam Date _______________________ Date of Birth _________________________ Age _______ Policy #Number _______________________

Sex M___F___ Height________ Weight_________ Blood Pressure__________ Pulse___________ Policy ID Number __________________________

Doctor: A physical examination is requested to determine the present condition of the above patient’s health and assist the prescribing NMC physician specialist in the evaluation of patient’s request for the one or more of the following NMC Medical Programs.

____Weight Loss Medication & Diet Program ____Testosterone Hormone Replacement Therapy for Men

____Bio-Identical Custom HRT for Women ____Testosterone + HCG Hormone Replacement Therapy for Men

____Erectile Dysfunction Treatment for Men ____Other Treatment_______________________________

Examining Physicians exam findings; assessment of patient’s general health and identification of any medical condition(s) that neeed to be considered or contraindicates patient’s undergoing any of the above treatments sought. National Medical has ordered a blood tests from a medical laboratory if patient is seeking hormone therapy and this report will be sent to the NMC prescribing physician.

____________________________________________________________________________________________________________________________

To Examining Physician: Please fax (1) a copy this completed and signed form; (2) Physical Examination Report; and (3) Your Patient Medical History Report to National Medical Clinic at fax number 1-866-629-2888 as soon as possible. Thank you

q Patient complains of erectile dysfunction or problems maintaining an erection

q Patient complains of infrequent spontaneous erections

q Patient complains of reduced or low interest in sex

q Patient complains of fatigue, anger or depression

q Patient complains of the lack of energy

q Patient complains of excessive weight or body fat

Would you like to be a participating provider in the National Medical National Network of Physicians and (1) receive new patients referrals with requests for physical examinations; or (2) prescribe National Medical testosterone HRT programs, medical weight loss and diet programs and other NMC medical treatments in consultation with other examining physicians, or (3) participate in both referral services? ____Yes or ____No. To enroll, please complete our online participating physician enrollment form at URL www.National MedicalClinic.com. There is no charge the referral of new patients to you as a NMC Network Physician. The physical exam fee for this patient is paid by NMC. If you have any questions, please phone 1-866-629-2888.

I have completed a physical examination of the patient identified above; I understand that a National Medical Clinic specialist physician shall evaluate the findings entered into this form, my physical exam report, my patient’s medical history, and appropriate medical diagnostic tests NMC has ordered in assessing subjective and objective findings and in the formulating of a plan of treatment. The consulting National Medical Clinic prescribing specialist physician, who receives this physical examination report, shall be solely responsible for deciding whether to issue this patient a prescription for any National Medical treatment protocol.

q I consent to an ongoing relationship with this patient; agree as a consulting physician to supervise the medical treatment identified should the need arise, including the use of the above medication if such medication is prescribed by a National Medical Clinic physician.

_________________________________________Date _____________ ______________________________________

Signature of Examining Physician Patient’s Signature authorizes the Examining

Physician to releases this completed form, patient’s physical exam report and medical history via fax or postal mail to National Medical Clinic and its consulting independent physicians.

__________________________________________________ (________)___________________________

Printed Name of Examining Physician Examining Physician’s Office Phone Number