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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