Women's Hormone Questionnaire
Lab Order Request
Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Do you have a decrease in libido (sex drive)?
Please Select
YES
NO
Is your motivation decreasing?
Please Select
YES
NO
SOMETIMES
Do you have a lack of energy?
select
Yes
NO
Sometimes
Do you have a decrease in strength and/or endurance?
select
YES
NO
SOMETIMES
Does it take longer to recover from physical activity?
Please Select
YES
NO
Sometimes
Have you noticed a decrease for "enjoyment of life?" (a lack of zest for life)
Please Select
YES
NO
SOMETIMES
Please Select
Do you have a hard time losing weight and/or keeping weight off?
Please Select
YES
NO
Do you feel sad, depressed, anxious, or grumpy?
Please Select
YES
NO
SOMETIMES
MOST OF THE TIME
Have you lost height?
Please Select
YES
NO
MAYBE
NOT SURE
Do you wake up feeling exhausted after getting a healthy amount of sleep?
Please Select
YES
NO
SOMETIMES
SECURE FORM- Enter Payment Information. $150-Cost of Lab Order for Hormones
CARD NUMBER
CARDHOLDER
CVC
EXP
Postal / Zip Code
Which treatment(s) are you interested in?
Optimized Hormone Pellets
Testosterone shots or cream
Growth Hormone Peptides
The O Shot (Vaginal injections)
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)
I want to pay
$150- less comprehensive labwork order
$300- - Most comprehensive labwork order (recommended)
I want to go to my own lab that takes my insurance and will coordinate with Insurer
I authorize Quintessence Health and Wellness to process my payment information for $150-$300 for lab orders done from Quest Diagnostics or use my insurance.
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