BIO-IDENTICAL HORMONE REPLACEMENT THERAPY FOR Male/Female
Requesting Lab Order
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Phone Number
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Email
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Do you have a decrease in libido (sex drive)?
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YES
NO
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Men-Are your erections less strong?
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YES
NO
SOMETIMES
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Women do you have vaginally dryness more frequently?
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Yes
NO
Sometimes
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Do you have a decrease in strength and/or endurance?
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YES
NO
SOMETIMES
Do you have a lack of energy?
select
Yes
NO
Sometimes
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Does it take longer to recover from physical activity?
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YES
NO
Sometimes
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Do you have a hard time losing weight and/or keeping weight off?
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YES
NO
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Have you noticed a decrease for "enjoyment of life?" (a lack of zest for life)
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YES
NO
SOMETIMES
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Do you feel sad, depressed, anxious, or grumpy?
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YES
NO
SOMETIMES
MOST OF THE TIME
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Have you lost height?
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YES
NO
MAYBE
NOT SURE
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Do you wake up feeling exhausted after getting a healthy amount of sleep?
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YES
NO
SOMETIMES
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Select
Which treatment(s) are you interested in?
HORMONE REPLACEMENT Pellets
Testosterone Booster
Growth Hormones/Peptides
The Mars or Venus Shot (Penis or Vaginal injections for sexual wellness)
Couple's pricing or ALL of the above
Which route of administration do you prefer?
Injections (I can inject myself)
Testosterone Cream
Oral (Capsules/Tablets/ODT)
New and improved Pellet (lasts 6 mnths)
Which labs would you like ordered?
Hormones and Testosterone $150
Include Cortisol and Thyroid +$50
Everything Possible ($300 total)
None
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