Doctor Checking a Form
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MEDICAL HISTORY AND SCREENING FORM

Please write your name as shown on your Drivers License or ID*

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*We are going to need copy of your driver's license prior to ordering medication. Please write down your driver's license number and upload a copy of the license below.

Upload File

*All files are stored on secure server. Get in touch with us if you would like to know how we handle your files and data.

REVIEW OF SYMPTOMS

If you have any of the symptoms below, please check the appropriate boxes, otherwise leave them blank !

General

Hormones

Skin

Allergies

Eyes/Nose/Ears/Mouth/Throat

Lungs

Heart

Gastrointestinal

Musculoskeletal

Billing information

Please note that this section is optional !

Is your card registered on the address above ?

If "No" Please fill the billing address that the card is registered on!

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Card Type

INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPY

Please read the following and sign !

I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them, and the risks associated with taking hormones including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are risks if I take any medication, including HRT.  I have discussed these risks and the reasons for taking them, with my provider and I want to proceed with therapy.  I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT, and I agree to follow the ultimate advice and recommendations of my provider.  I understand that Hormone therapy is very individualized and that there are no guarantees that these measures will be effective, and I am participating in this therapy with that understanding.  I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them and guide me through a therapy for me.

To sign use Left Click and drag mouse or your finger/stylus if using touch screen

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