Hormone Optimization Medical Intake Form
*I understand that my practitioner relies on the medication information I provide to him/her for my care and that any medication misinformation can result in hospitalization or death. I also understand that prevention of dangerous drug interactions and duplications of medications are a top priority for my safety. By typing my name below, I acknowledge that the medication information I am providing is accurate and complete and I give permission for the facility to review my medication history.
The answers I have provided are true, accurate and complete to the best of my knowledge.