BHRT New Patient Info (HRT Form #1)

Bio-Identical Hormone Replacement - New Patient Information
Name

First NameLast Name
DOB*
Preferred Phone*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
May we contact you?

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Practitioner Information

First NameLast Name
Practitioner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practitioner Phone
Practitioner Fax
Who referred you to Good Day?
Please Read and Sign
I understand that payment is requested at time of service.
Fee Schedule*

$250 for New Patient Consultation – typically two initial appointments that include a recommendation to your medical practitioner.$100 for follow-up, either by phone or through email. Follow-up usually results in informing your medical practitioner with a progress report and often a request for a change in your prescription.
Authorization to Release Medical Information: I hereby authorize Good Day Pharmacy and any licensing organizations to review and obtain copies of my medical record (e.g., medical history, prescription formulas, patient notes, patient lab tests, etc), and insurance information, as they relate to my therapy, to my reimbursement to Good Day Pharmacy, and for care coordination, quality assurance, accreditation, or licensing reviews. I also hereby authorize Good Day Pharmacy to furnish to my insurance carriers and other health care providers, any medical history, lab testing, proof of services rendered, or plan of care recommended.

I have read and understood all the information stated above.
Signature*

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Date*

MonthDayYear
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Bio-Identical Hormone Replacement - New Patient Information

Please Read and Sign