Patient Intake Form

Patient Information:

• Full Name:
• Date of Birth:
• Sex Assigned at Birth:
• Current Gender Identity:
• Phone Number:
• Email:
• Address:
• Emergency Contact:

Health History:

• Current Medications:
• Allergies:
• Chronic Medical Conditions:
• Surgeries/Hospitalizations:
• Family History (e.g., cancer, heart disease, clotting disorders):

Lifestyle:

• Smoking Status: ☐ Never ☐ Former ☐ Current
• Alcohol Use: ☐ Never ☐ Occasionally ☐ Regularly
• Exercise: ☐ Sedentary ☐ 1–2x/week ☐ 3–5x/week ☐ Daily
• Sleep: ☐ <5 hrs ☐ 6–7 hrs ☐ 8+ hrs

Hormone Symptoms (Check all that apply):

• ☐ Fatigue
• ☐ Hot flashes / Night sweats
• ☐ Mood swings / Irritability
• ☐ Poor concentration / Memory loss
• ☐ Low libido
• ☐ Vaginal dryness / Erectile changes
• ☐ Hair thinning or loss
• ☐ Weight gain / Difficulty losing weight
• ☐ Insomnia / Sleep difficulty
• ☐ Anxiety / Depression
• ☐ Cold intolerance / Heat intolerance

Goals for Hormone Therapy:

• ☐ Improve energy
• ☐ Improve sexual function
• ☐ Improve mood and cognition
• ☐ Support bone health / aging
• ☐ Menopause or andropause symptom relief

Previous Hormone Therapy:

• ☐ Yes ☐ No If yes, describe:

Consent & Signature I acknowledge that the information provided is accurate to the best of my knowledge.

Signature: _____________________________
Date: _______________

Telehealth Consent Form

Purpose: This form explains your rights and responsibilities regarding care provided via telehealth.

Definition of Telehealth: Telehealth refers to healthcare services provided remotely via secure video or phone communication.

What to Expect:

• You will receive medical advice, diagnosis, or treatment through telecommunication technology.
• All information is confidential and complies with HIPAA privacy laws.
• You may be asked to complete lab work at an approved local laboratory.

Benefits:

• Convenience and access to care without travel.
• Access to specialists regardless of location.

Risks:

• Technology failure or disruption.
• Delays due to incomplete information or inability to examine certain areas in-person.

Your Rights:

• You may stop or decline telehealth services at any time.
• You have the right to access your medical records.

Your Responsibilities:

• Provide accurate information and updates to your provider.
• Ensure a private, secure environment for your sessions.
• Follow up with lab tests, imaging, or referrals as advised.

Consent Acknowledgment: By signing below, I confirm that:

• I understand the risks and benefits of telehealth.
• I consent to receive medical services via telehealth.
• I understand I may withdraw consent at any time.

Signature: _____________________________
Date: _______________

HRT/BHRT Informed Consent Form

Purpose: This form outlines the potential benefits, risks, and responsibilities associated with Hormone Replacement Therapy (HRT) and Bioidentical Hormone Replacement Therapy (BHRT).

Benefits of HRT/BHRT May Include:

• Relief of menopausal/andropausal symptoms
• Improved energy and mood
• Increased libido and sexual function
• Support for bone density and cardiovascular health
• Enhanced cognitive clarity and overall well-being

Potential Risks and Side Effects:

• Acne or oily skin
• Breast tenderness or enlargement
• Mood swings, anxiety, or irritability
• Increased red blood cell count (testosterone)
• Blood clots (rare, typically with oral estrogen)
• Fluid retention, weight changes
• Virilization (in women taking testosterone)

Monitoring: I understand that regular lab tests and follow-up visits are necessary for safe and effective treatment. These include hormone levels, CBC, PSA (men), lipid panels, and others as needed.

Medication Use: I agree to use medications only as prescribed and to report any adverse effects immediately. I will not share or sell any prescribed hormone medications.

Contraindications: I confirm that I have disclosed any personal or family history of cancer, blood clots, heart disease, or other relevant conditions. I understand that HRT may not be recommended for individuals with certain medical histories.

Voluntary Participation: I understand that HRT/BHRT is elective and that I may stop treatment at any time. I acknowledge the therapy is tailored to individual symptoms and labs and may require dose adjustments over time.

Consent Acknowledgment: I have read and understood the above. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I consent to initiate or continue hormone therapy under the guidance of my provider.

Signature: _____________________________
Date: _______________

HIPAA Acknowledgment Form

Purpose: To inform you of your rights under the Health Insurance Portability and Accountability Act (HIPAA) and acknowledge receipt of our privacy practices.

Your Rights Under HIPAA:

• You have the right to review and receive a copy of your medical records.
• You can request amendments to your health records.
• You can request limits on the use and disclosure of your information.
• You can request confidential communications.
• You can receive a list of disclosures of your health information.

Our Responsibilities:

• We are required by law to maintain the privacy and security of your protected health information (PHI).
• We will notify you promptly if a breach occurs that may have compromised your PHI.
• We must follow the duties and privacy practices described in our Notice of Privacy Practices.

Acknowledgment: I acknowledge that I have been offered a copy of the Notice of Privacy Practices and that I understand my rights related to the confidentiality and use of my medical records.

Signature: _____________________________
Date: _______________