Hormone Management Intake Form

What are the top three improvements you would like to see from hormone management?

By checking the box below, I acknowledge and consent to receive healthcare services through telemedicine/virtual care.

I understand and acknowledge that:

• Telemedicine involves the use of electronic communication technology to provide healthcare services remotely.
• My provider will evaluate my symptoms, medical history, medications, laboratory information, and other available health information during my virtual consultation.
• A virtual examination may be more limited than an in-person physical examination.
• Certain medical conditions may require an in-person examination, laboratory testing, imaging, specialist evaluation, or other medical services.
• My provider may determine that hormone therapy is not medically appropriate for me.
• Treatment recommendations and medication decisions will be based on my individual medical history, symptoms, laboratory results, risks, benefits, and clinical assessment.
• No specific medication, treatment outcome, or symptom improvement is guaranteed.
• I have the opportunity to ask questions and discuss the risks, benefits, alternatives, and expected monitoring associated with treatment.
• I will provide complete and accurate information regarding my medical history, medications, allergies, symptoms, reproductive status, and laboratory results.
• I understand that providing incomplete or inaccurate information may affect my care.
• Telemedicine may have technical limitations, including interruptions or inability to adequately evaluate certain medical conditions.
• I understand that virtual care is not appropriate for medical emergencies.
• If my provider determines that I require urgent or emergency in-person care, I will follow the recommendation to seek appropriate medical attention.

I certify that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that my healthcare provider will use this information as part of my virtual medical evaluation.