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Confidential BHRT Consultation Form

Our compounding specialists work together with patients and prescribers to provide customized bio-identical hormone replacement therapy that provides the needed hormones in the most appropriate strength and dosage form to meet each woman’s specific needs. Hormone replacement therapy should be initiated carefully after a woman’s medical and family history has been reviewed. Every woman is unique and will respond to therapy in her own way. Close monitoring and medication adjustments are essential.

If you feel as though you could benefit from Bio-identical Hormone Replacement Therapy, fill out our consultation form below or click here to print out PDF version, then fax it back or bring it in to your appointment. Your privacy is a top priority. This information is secure and is guaranteed to only go directly to the pharmacists.

For your convenience you can send your forms three different ways:

  1. Fill out the online Bio-identical Hormone Replacement Therapy (BHRT) form below and sent it straight to us in our secure submission form.

  2. Print and fill out the PDF version for BHRT and bring it in during your appointment.

  3. Print and fill out the PDF version for BHRT and fax it to us at 760.834.6297.

Your privacy is a top priority; this information is secure and will only go directly to the pharmacists.

 

Please complete the form below:
Fields marked with * are required.

Name *
Name
Birthdate *
Birthdate
Address
Address
Phone *
Phone
Medical History
Current Intake
Check all the products you are regularly using.
Please list the medication(s) name, strength, date started and how often you take it per day.
Please list the date you started, date you stopped, and the reason for stopping.
Symptoms
Please check the following that apply:
Hot Flashes
Please indicate the degree of severity:
Night Sweats
Please indicate the degree of severity:
Vaginal Dryness
Please indicate the degree of severity:
Incontinence
Please indicate the degree of severity:
Bleeding Changes
Please indicate the degree of severity:
Fibrocystic Breast
Please indicate the degree of severity:
Weight Gain
Please indicate the degree of severity:
Fluid Retention
Please indicate the degree of severity:
Dry Skin/Hair
Please indicate the degree of severity:
Hair Loss
Please indicate the degree of severity:
Anxiety
Please indicate the degree of severity:
Depression
Please indicate the degree of severity:
Mood Swings
Please indicate the degree of severity:
Irritability
Please indicate the degree of severity:
Headaches
Please indicate the degree of severity:
Breast Tenderness
Please indicate the degree of severity:
Cramps
Please indicate the degree of severity:
Difficulty Falling Asleep
Please indicate the degree of severity:
Difficulty Staying Asleep
Fatigue
Please indicate the degree of severity:
Loss of Memory
Please indicate the degree of severity:
Foggy Thinking
Acne
Arthritis
Please indicate the degree of severity:
Decreased Sex Drive
Please indicate the degree of severity:
Harder to Reach Climax
Please indicate the degree of severity:
Stress
Sex Desire Level