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Hallandale Compounding Pharmacy

Human Growth Hormone (hGH) Profile Agreement

Clinic Name: ______________________________________________Contact Name: ___________________________________________ Doctor's Name (one profile per doctor): ______________________________________________________________________________

HALLANDALE COMPOUNDING PHARMACY DOES NOT FILL PRESCRIPTIONS THAT TREAT PATIENTS FOR ATHLETIC PERFORMANCE OR ENHANCEMENT

What percentage of the clinics patients are living out of the State the clinic is located in? _________________________________________________________________________________________________________ What percentage of out of state patients are physically seen by the Doctor signing this profile? _________________________________________________________________________________________________________ What steps are taken to ensure that the out of state patient is seen by the Doctor signing this profile? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Upon request Hallandale Compounding Pharmacy may ask for blood work or diagnosis for any patient on Human Growth Hormone. Does this pose a problem for the clinic? _________________________________________________________________________________________________________ Human Growth Hormone (HGH) is the active ingredient in a number of human prescription drugs approved for marketing in the U.S. under new drug applications (NDAs). FDA-approved HGH can be legally prescribed for a limited number of conditions including: * * * * * * * hormonal deficiency that causes short stature in children; long-term treatment of growth failure due to lack of exogenous GH secretion; adult growth deficiency long-term treatment of short stature associated with Turner Syndrome; adult short bowel syndrome; adult deficiency due to rare pituitary tumors or their treatment; and muscle-wasting disease associated with HIV/AIDS.

When prescribing HGH does the Doctor signing this profile prescribe it according to what its legal indications are (stated above)?

_________________________________________________________________________________________________________

I certify that all the information given on this profile was provided voluntarily and is true and complete. (please sign) Doctor: ________________________________________________ Date: __________________________________ The information will be used to make a determination of taking on your newly acquired business and all information given will remain confidential between both parties at all times.

Hallandale Compounding Pharmacy - 1109 E. Hallandale Beach Blvd. - Hallandale Beach - FL - 33009 - 954-455-3822 pharmacy - 954-381-8164 fax

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HGH Profile Agreement

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