Please list any medical problems or illnesses you have had or continue to have. Include any hospitalizations and accidents with approximate dates.
Please remember that this information is strictly confidential and will be used only to address your symptoms and/or complaints.
Please answer if sleep is an issue you would like addressed
Female Patients please skip to next section*
Please review each category and mark which symptoms have been bothersome on a scale of 1 through 4
1-no symptoms 2-minimal 3-moderate 4-severe
Male Patients please complete previous sections*
Male Patients please skip to next section*
Within the medical community, there are opposing views with respect to the use of bioidentical hormonal replacement therapies. The use of bio-identical hormones is not recommended to be used to treat medical conditions, and is an off-label therapy used for symptoms of andropause, menopause, low energy, and mood symptoms. While numerous safety measures are taken by our health care providers and staff, incidental events may occur that are beyond the control of our staff.
For this, I (the Patient) understand that bio-identical therapy does provide true medical benefit, and is being used at our centre to lessen or treat non-life threatening symptoms you have identified as bothersome, undesirable, and unwanted. I also understand and am aware that there are a number of available prescription hormone replacement therapy I can receive from my regular provider (eg. Premarin, Prometrium, Climara, Estrace, Angeliq, Estalis, and Androgel). I have waived this decision and want to use bio-identical hormones from a compounding pharmacy to treat my symptoms.
It is therefore expressly agreed that you are voluntarily participating in this program and all bio-identical hormonal replacement regiments, and the use of any medications and/or supplements is undertaken at your own risk. You are voluntarily participating in this program and assume all the risks. You hereby agree to waive any claims or rights you might otherwise
have to pursue legal action against the treating/healthcare provider and staff involved for the effects of injury to you on account of involvement in the Bio-identical Hormone Replacement Therapy Program. You have carefully read this waiver and fully understand that it is a release of liability.
A requirement for acceptance and continuation in the Bio-identical Hormone Replacement Therapy Program is adherence to routine cancer screening. You must have routine physical examinations as indicated by your health conditions. Your signature below indicates that you will comply by obtaining the cancer/prostate screening from your primary care provider within six months of beginning the Bio-identical Hormone Replacement Therapy Program and then according to current screening guidelines, which can be obtained through and followed with your primary care provider. You also understand that all primary care services will be managed by your current primary care provider. At our centre, we will only be managing symptoms related to hormone deficiency.
I have read the above and all of my questions have been answered to my satisfaction. I attest that I have truthfully completed the health history intake form and have declared all of my known medical conditions. I accept all terms and conditions of this program and I am consenting to participate voluntarily in this program.
Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patient when located at different sites.