• MEDICAL HISTORY AND SCREENING FORM

    General Information

  • Participant

  • Date Format: MM slash DD slash YYYY
  • What is/are your purpose(s) for participating in the HRT program?
  • Current Medical History

  • Check those questions to which you answer yes. Leave all others blank.
  • Women only answer the following:

  • Date Format: MM slash DD slash YYYY
  • Men and Women, both, answer the following:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Past Medical History

  • Note: include heart attack date.
  • We will need a copy of your current bloodwork and your drivers license prior to ordering medication. If you have them handy, please submit them here, otherwise please continue with the form.

  • Drop files here or
    Accepted file types: jpg, jpeg, png, pdf.
  • Drop files here or
    Accepted file types: jpg, jpeg, png, pdf.
  • Patient Authorization for Delivery of Medications

  • I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination. At the physician’s discretion you will be provided medications and/or services during your program at Viking Alternative Medicine. No Refund Policy *Viking Alternative Medicine reserves the right to have NO RETURN and NO REFUND policy.
  • I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination. At the physician’s discretion you will be provided medications and/or services during your program at PureHRT. No Refund Policy *PureHRT reserves the right to have NO RETURN and NO REFUND policy.
  • Informed Consent for Hormone Replacement Therapy

  • Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use and the liability is on the patient, not the doctor. When hormone levels are brought back to
    “normal” for your age there is much evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment. The medical frame of mind is always changing so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest information is. Please read the following and sign: I 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 different risks if I take any HRT medication. I have discussed these risks and the reasons for taking them, with my doctor. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT. I understand that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them for me.
  • OPTIONAL

    Credit Card Authorization Form

  • mm/yyyy
  • By signing this form, you give PureHRT permission to keep the above credit card on file and charge it for future orders. The card on file can be changed prior to your next transaction.

    You are authorizing PureHRT to charge and sign your card for future transactions

    *** PureHRT reserves the right to have a NO RETURN AND NO REFUND POLICY.***
  • By signing this form, you give Viking Alternative Medicine permission to keep the above credit card on file and charge it for future orders. The card on file can be changed prior to your next transaction.

    You are authorizing Viking Alternative Medicine to charge and sign your card for future transactions

    *** Viking Alternative Medicine reserves the right to have a NO RETURN AND NO REFUND POLICY.***

 

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