Forms Required for Hormone Therapy

 How to Sign Required Forms with DocuSign | Instructional YouTube Video

Get Started Step One REQUIRED
Click here to fill-out your MEDICAL HISTORY FORM and sign with DocuSign
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 online with DocuSign:

• Medical Treatment Agreement

• Credit Card Authorization

Get Started Step One REQUIRED
Fax us a copy, or email a high-resolution photo of your DRIVER'S LICENSE
FAX: (561) 658-6212  EMAIL: documents@andrologix.com
 

 


 

OPTIONAL FORMS:

DO NOT COMPLETE THE FOLLOWING FORMS UNLESS SPECIFICALLY REQUESTED TO DO SO.
Some forms may require Acrobat Reader. Click here to download reader now.

PBPM Annual Medical Review Form OPTIONAL
PBPM Annual Medical Review Form
PBPM Annual Lab & Vital Signs 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
PBPM TeleHealth Consent Form DOCUSIGN ELECTRONIC SIGNATURE
Medical Records Release Form (sign online)
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

 


 

PALM BEACH PREVENTIVE MEDICINE TELEHEALTH FORMS:

DO NOT COMPLETE THE FOLLOWING FORMS UNLESS SPECIFICALLY REQUESTED TO DO SO.

PBPM TeleHealth Physical Exam Form MUST BE COMPLETED BY EXAMINING PHYSICIAN AND FAXED BACK TO US
TeleHealth Physical Exam Form - PBPM
   CHOOSE ONLY ONE OF THE FOLLOWING CONSENT FORMS:
PBPM TeleHealth Consent Form MUST BE PRINTED, SIGNED AND FAXED
TeleHealth Consent Form - PBPM
PBPM TeleHealth Consent Form DOCUSIGN ELECTRONIC SIGNATURE
TeleHealth Consent Form - PBPM
   CHOOSE INSTRUCTION VIDEO FOR ANDROID OR IPHONE:
PBPM VSee Instructions: Android YOUTUBE VIDEO
Android VSee Video Instructions - PBPM
PBPM VSee Instructions: iPhone YOUTUBE VIDEO
iPhone VSee Video Instructions - PBPM

 

 

Andrologix Health and Wellness is a National Network of experienced physicians who specialize in hormone replacement therapy – it’s all we do. For over 15 years we’ve been improving the lives of thousands of men and women just like you!

Contact us today and let us create a custom therapy designed to address your specific needs. Balanced hormone levels are an essential part of an active lifestyle, a lifestyle that promotes good health, vitality and longevity.

At Andrologix Health and Wellness, we're committed to ensuring that your privacy is protected at all times. Your information is kept 100% confidential and will never be shared with a third party, for any reason, ever!

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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