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 form.
Get Started Step One

REQUIRED
Fill-out and sign online with DocuSign:

Medical Management Form & Authorization to Release Information to Myself

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.

Partner Physician TeleHealth Consent Form DOCU-SIGN ELECTRONIC SIGNATURE
Telehealth Consultation Consent - Partner Physician (sign online)
PBPM Annual Medical Review Form PRINT, COMPLETE, SIGN AND FAX
PBPM Annual Medical Review Form
PBPM Annual Lab & Vital Signs PRINT, COMPLETE, SIGN AND FAX
PBPM Annual Lab & Vital Signs
Universal Annual Lab & Vital Signs PRINT, HAVE COMPLETED BY EXAMINER, AND FAX - [Vitals Form for 3rd party Examiners]
Universal Annual Lab & Vital Signs
Andrologix Health: Medical Records Release Form PRINT, COMPLETE, SIGN AND FAX
Medical Management & Authorization to Release Information to Myself
Andrologix Health: Medical Records Release Form PRINT, COMPLETE, SIGN AND FAX
Medical Records Release to 3rd Party
PBPM TeleHealth Consent Form DOCU-SIGN ELECTRONIC SIGNATURE
Medical Records Release to 3rd Party (sign online)
Andrologix Health: Trimix Consent Form PRINT, COMPLETE, SIGN AND FAX
Trimix Instructions and Consent Form
Andrologix Health: 3rd Party CC Authorization PRINT, COMPLETE, SIGN AND FAX
3rd Party CC Authorization
Andrologix Health: Credit Card Authorization PRINT, COMPLETE, SIGN AND FAX
Credit Card Authorization Only
Andrologix Health: Required Lab Work OPTIONAL
Required Lab Work

 

 


 

PBPM TELEHEALTH FORMS & INSTRUCTIONS:

DO NOT complete any of the following unless you are a new or existing patient of our West Palm Beach, Florida affiliate clinic.

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: Print and Fax, OR Sign Online:
PBPM TeleHealth Consent Form MUST BE PRINTED, SIGNED AND FAXED BACK TO US
TeleHealth Consent Form - PBPM
PBPM TeleHealth Consent Form DOCU-SIGN ELECTRONIC SIGNATURE CAN BE SIGNED ONLINE
TeleHealth Consent Form - PBPM

DOXY.ME VIDEO VISIT INSTRUCTIONS:

PBPM TeleHealth Consent Form PDF DOCUMENT: DOXY.ME TELEHEALTH VIDEO VISIT INSTRUCTIONS
How to Check In for my TeleHealth Visit with DoxyMe
PBPM TeleHealth Consent Form 2-MINUTE VIDEO: DOXY.ME TELEHEALTH VIDEO VISIT INSTRUCTIONS
How to Check In for my TeleHealth Visit with DoxyMe

INSTRUCTIONS FOR PHYSICIANSLAB URINE TESTS:

Collection Instructions for Urinary and Bloodspot Tests INSTRUCTION VIDEOS FROM PHYSICIANSLAB
Collection Instructions for Male & Female Urine Tests

 

 

 

Andrologix Health and Wellness is a National Network of experienced physicians who specialize in hormone replacement therapy – it’s all we do. For over 18 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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