Woocommerce Medical Form Name(Required) First Middle Last Email(Required) Phone(Required)Alternate NumberBirthday(Required) MM slash DD slash YYYY Ethnicity(Required)American IndianAlaskan NativesAsianBlack African AmericanHispanic or LatinoWhiteNative Hawaiian or Pacific IslanderOtherPrefer Not To SaySex(Required)MaleFemaleOtherAddress(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Number(Required) 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.Upload Driver's License(Required)Max. file size: 5 MB.What is your purpose for reaching out to Rejuvinate HRT?(Required)Medical History(Required)MedicationsSupplementsAre you allergic to any medications ?REVIEW OF SYMPTOMSIf you have any of the symptoms below, please check the appropriate boxes, otherwise leave them blank !General Change in Appetite Change in weight Fatigue Difficulty Sleeping Anxiety Depression Hormones Poor Motivation Low Sex Drive Poor sexual function Brain fog Irritability Mood Instability Irregular, Heavy or No Menstrual Periods Skin Sores That Don't Heal Dry Skin Hair changes Allergies Seasonal Allergies Hives Food Allergies Eyes/ Nose/ Ears/ Mouth/ Throat Loss of Vision Difficulty Swallowing Lump in the Neck Voice Changes Lungs Shortness of Breath Persistent Cough Wheezing Heart Chest Pain Heart Racing Swollen Ankles Gastrointestinal Heartburn Frequent Nausea Abdominal Pain Frequent Diarrhea/ Constipation Musculoskeletal Muscle/Joint Soreness Generalized Weakness Difficulty Recovering Have you ever been on any form of HRT ? How long ago ?INFORMED CONSENT FOR HORMONE REPLACEMENT THERAPYI 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.I agree to the HRT policy Yes Name First Middle Last I agree to the HIPAA FORMS Service Privacy Statement ! Yes Please Sign Here(Required)
