Welcome to Health N Wellness RX

Congratulations on taking the first step toward a healthier, more optimized life.

At HNW Rx, under the guidance of Dr. Agresti MD and Wellness Strategist Gina Trochiano, CHHC, we invite you to complete the brief questionnaire below. This allows us to better understand your current challenges, personal goals, and wellness priorities.

You’ll also receive a detailed overview of our program, including investment options, how the process works, and what to expect should you choose to move forward with us.

First Name *

Last Name *

Phone *

Email *

Address

Street Address *

City *

State *

Country *

Postal code *

Is your mailing address the same as your home address? *

Yes

Please enter your mailing address here

Select your service location *

Instagram URL

Date of birth *

Gender: *

Height in feet *

Height in inches *

Current weight in lbs *

Pharmacy Name *

Pharmacy City *

Pharmacy State *

Are you currently taking any medications? If so, list below.

Upload a picture of the front of your driver's license or government issued I.D. *

Do you have health insurance? *

Yes

HNW Rx is a membership-based program and does not accept insurance. However, bloodwork should be covered by your health insurance. Please contact your insurance provider for any additional questions.

What lab is covered under your insurance? *

LabCorp

Quest

None

We require this information to fill out the proper lab requisition for bloodwork. Contact your insurance provider if you have an concerns.

Upload a picture of the FRONT of your insurance card, for verification *

Upload a picture of the BACK of your insurance card *

Ready to move forward? *

Yes. Provide me with details on the next steps for obtaining bloodwork.

Not quite. Please have a Wellness Advisor contact me.

Terms and Acknowledgments:

I understand that there is no obligation to move forward, and my decision is entirely voluntary.

I acknowledge that it is my responsibility to check with my insurance provider to confirm coverage. HNW Rx is not responsible for any lab billing.

In the absence of health insurance coverage, I may request an abbreviated lab requisition from HNW Rx.

I understand there is a non-refundable one-time fee of $275 for the initial lab review, due at the time of booking an appointment.

Following the review, Dr. Agresti and his team will create a protocol tailored to my needs. I have the option to approve, adjust, or choose not to proceed, and there is no commitment or additional cost if I wish not to move forward.

Moving forward, I understand that quarterly lab review payments are included in my membership.

Please select 'Yes' if you agree to the terms mentioned above, or 'No' if you choose not to proceed at this time. *

Yes

HIPAA Compliance Consent

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.The notice contains a patient’s rights section describing your rights under the law.

You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations.

We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

I understand that: SELECT ALL BOXES BELOW *

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The practice reserves the right to change the privacy policy as allowed by law.

The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

The practice may condition receipt of treatment upon the execution of this consent.

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.