Forms Required for Hormone Therapy

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Get Started Step One REQUIRED
MEDICAL HISTORY FORM

INSTRUCTIONS:

[a] Fill out the form COMPLETELY.
[b] Press the "Submit Medical History Form" button at the bottom of the form.
[c] Then PRINT the form, SIGN it, and FAX it to (561) 658-6212.

  Click here to fill-out your MEDICAL HISTORY FORM
For Women Only FOR WOMEN ONLY!
Women, also fill-out and sign the MEDICAL HISTORY SEC.1B and fax it to (561) 658-6212
Get Started Step One REQUIRED
Fill-out and sign the MEDICAL TREAMENT FORM and fax it to (561) 658-6212
Get Started Step One REQUIRED
IDENTIFICATION: Fax a copy of your Driver's License to (561) 658-6212
Get Started Step One IMPORTANT: BE SURE YOU GET OUR EMAILS!
ADD US TO YOUR EMAIL ADDRESS BOOK, NOW!

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OPTIONAL FORMS:
You DO NOT need to complete the following forms unless you are specifically requested to do so.

Andrologix Health: Medical Records Release Form OPTIONAL
PBPM Annual Medical Review Form
Andrologix Health: Medical Records Release Form OPTIONAL
PBPM Annual Lab & Vital Signs
Andrologix Health: Medical Records Release Form OPTIONAL
Authorization to Release Health Information to Myself
Andrologix Health: Medical Records Release Form OPTIONAL
Medical Records Release Form
Andrologix Health: Trimix Consent Form OPTIONAL
Trimix Instructions and Consent Form
Andrologix Health: 3rd Party CC Authorization OPTIONAL
3rd Party CC Authorization
Andrologix Health: Credit Card Authorization OPTIONAL
Credit Card Authorization Only
Andrologix Health: Required Lab Work OPTIONAL
Required Lab Work

 

PBPM TELEHEALTH FORMS:
You DO NOT need to complete the following forms unless you are specifically requested to do so.

Andrologix Health: Medical Records Release Form PBPM TeleHealth Consent Form
Andrologix Health: Medical Records Release Form PBPM TeleHealth Annual Vitals Form
Andrologix Health: VSee Physical Exam Form PBPM TeleHealth Physical Exam Form
   

 

 

 

 

All of your information is kept 100% confidential. Contact us today! Our doctors specialize in anti-aging and hormone replacement. Let us create a custom therapy designed to address your specific needs.

If you have any questions, please contact us at 877-741-6069.

For more information on the following subjects, please click the links below.

Therapies cannot be provided unless your physical exam, medical history, and lab work show a clinical need. Completing the required forms, lab work and exams doesn't automatically qualify you for treatment. Only the prescribing physician can determine if you qualify.

The content of this website is provided for informational purposes only and should not be construed as medical advice. Consult your healthcare provider before starting any therapy program.

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