INTAKE TESTOSTERONE/HORMONE Male/female

Quintessence Health and Wellness

HORMONE OPTIMIZATION INTAKE FORM FOR MEN/WOMEN
Name*
Date Of Birth*

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Email Address*
example@example.com
Address*

Street Address

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Phone Number*
SSN # (Needed for lab work)*
Occupation
Emergency Contact Name
Emergency Contact Phone Number
How did you hear about us?
MALE AND FEMALE HORMONE Replacement Therapy Membership Options. 6 month minimum (Select Membership Option for Enrollment)*

Platinum ($250 Enrollment-$75/Month)Gold ($150 Enrollment -$85/Month)Bronze ($75 Enrollment -$100/Month)FEMALE PELLET TOTAL HORMONE THERAPY ($200/Month 5- 6 month Insertions)MALE PELLET TOTAL HORMONE THERAPY ($250/Month 5- 6 month Insertions)Pay 6 months upfront for Pellet Therapy- save 15% total-$1000 Bi yearly including follow ups & next Lab order
Smoke Cigarettes?

YesNoVape
Drink Alcohol?

YesNo
Do you currently use Illegal Drugs? (Heroin, Methamphetamine, Cocaine, Marijuana,etc)

YesNo
Symptoms of Hormone Imbalances*

Daytime SleepinessDecreased ConcentrationDepressionDifficulty Learning New ThingsErectile DysfunctionVaginally DrynessIncreasing FatigueMemory LossMoodinessPoor Sleep HabitsBrain Fog
Have you had your Hormone levels checked recently?*

YesNoLet's order labs now for $150Consult first
Have you ever used Testosterone or hormones before?

YesNo
If yes, How long ago? For how long? What Kind and Dose?
Health History Questionnaire (Please Check All that Apply):

AllergiesAsthma / COPDAuto-Immune DisorderBlood ClotsBlood in UrineBronchitisChronic ConstipationChronic DiarrheaCongestive Heart FailureDecreased Urinary ForceDepressionDiabetesEdemaEnlarged Prostate (BPH)Family History of CancerGall StonesHeart AttackHeart FailureHeart MurmurHigh CholesterolHistory of CancerHypertensionKidney/Bladder InfectionLactose IntoleranceLiver InfectionIrregular HeartbeatOn/Off Urine FlowOveractive BladderPainful UrinationPersonality DisorderPneumoniaProstate IssuesShortness of BreathSleep ApneaUnwanted Weight LossVascular Disease
Rate your quality of sleep:
(1-Worst 10-Best)
List all current medications
Prior Surgeries w/approximate dates
Known Allergies
What exercise to you do on a regular basis? (check all that apply)

BikingCalisthenicsExtreme SportsJoggingOther CardioPower LiftingResistance TrainingRunningSports TeamSwimmingWalkingWeightlifting
Consent for Testosterone Replacement/ Hormone Therapy Agreement

It is important to understand that all medicine is an inexact science. Although we will carry out your treatment carefully, results may vary in their degree of success. It is quite natural for a patient undergoing Bio-Identical Hormone Therapy Replacement Therapy to want to know that everything will turn out all right. While most of the time this is the case, it is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Testosterone Replacement Therapy. You should also be aware of the alternatives to Bio-Identical Hormone Replacement Therapy, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weight your options or consult another health care provider. Please review the following statements, which discuss informed consent.

Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all your questions to your satisfaction.

I agree that, while a patient of Quintessence Health & Wellness, LLC., I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro-hormones or any additional testosterone supplementation not provided by Quintessence Health & Wellness LLC. during my treatment plan. At any time, if use of these items is discovered, I understand I will be discharged as a patient of Quintessence Health & Wellness. And the information I have provided is true and accurate to the best of my knowledge.
Check each statement that you have read, understand, and agree with.*

This is my consent Quintessence Health & Wellness, LLC., including any physician or nurse who works with the company, to begin my treatment for Hormone Replacement Therapy..It has been explained to me, and I fully understand, that occasionally there are complications with this treatment such as Acne, Breast Enlargement, Mood Swings, as well as the following:Extra fluid in the body- This can cause problems for patients with heart, kidney, or liver disease.Sleep disturbance - This is called sleep apnea and is more likely to occur with patients who have lung disease or are overweight.Prostate enlargement- this may cause problems with urinating.Changes in cholesterol levels, red blood cell levels, PSA levels, liver function enzymes, and other hormone levels which will be monitored with periodic blood tests.I understand that I will have periodic blood tests to monitor my blood levels.I understand there is no guarantee as to the result and that if I stop treatment, my condition may return or get worse.I have had an opportunity to discuss with Quintessence Health & Wellness and its medical practitioners my complete past medical and health history including any serious problems and/or injuries. All of my questions concerning the risks, benefits and alternatives have been answered. I am satisfied with the answers.I understand that the physical exam by Quintessence Health & Wellness LLC. does NOT replace a full physical exam by a personal physician.I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels and a comprehensive metabolic panel. If I do not have a personal physician, Quintessence Health & Wellness LLC. will assist in locating one for me.I understand that prolonged BHRT therapy may reduce ejaculate volume and reduce sperm count, possibly affecting fertility.I have been trained on how to administer intramuscular and subcutaneous injections from a licensed medical practitioner who is approved to perform such tasks.I understand that if I need to reschedule, I must call or text 801-930-9381, BEFORE the date of my scheduled appointment. If I call, text, or email on the day of my appointment to reschedule, I will be responsible for a $50 fee, compensating the Qualified Medical Professionals' time.
Membership Options. (Select same option as above for Membership Enrollment)*

Platinum ($250 Enrollment-$85/Month)Gold ($150 Enrollment -$95/Month)Bronze ($75 Enrollment -$110/Month)FEMALE PELLET TOTAL HORMONE THERAPY ($200/Month) Insertions every 4-5 months *Labs NOT InlcudedMALE PELLET TOTAL HORMONE THERAPY ($250/Month) Insertions every 5-6 months **Labs NOT Included
Preferred Pharmacy (ONLY For At Home TRT Members)
Pharmacy Phone Number
Please enter a valid phone number.
Payment Information*

Cardholder Name (as shown on the card):

Card Number:

Expiration Date: CVV

Cardholder ZIP Code (from credit card Billing address)
I authorize Quintessence Health and Wellness to charge my card for recurring payments, for my Testosterone Replacement Therapy. I understand that recurring payments will processed on a monthly basis and accept the terms and conditions for the membership for which I have selected above. I also authorize Quintessence H&W to charge my card for any additional services, products, supplies, and or shipping that may be necessary in my treatment plan, that will be discussed between the Physician and I during my therapy treatment.
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