Health History

Patient Gender*

Patient Name*

First NameLast Name

Patient Birth Date*

MonthDayYear

Age*

Address. Services are for For Pennsylvania Residents Only *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Preferred Phone Number *

Area CodePhone Number

Drivers License Number and Issuing State (required) *

Patient Height (ex5.7)*

Patient Weight (in lb)*

Patient E-Mail*

Reason for visit:*

ex: Routine Check-up

Referred by someone? Enter their name for credit*

Please list if you have any drug allergies*

ex: Penicilin

Have you ever experienced allergic reaction, specifically anaphylaxis?*

Please list your current medications*

Have you ever had (Please check all that apply)*

Any surgeries?

Have you taken hormone replacement before?*

If so, what type and when

I understand initial and follow up labs are required for treatment? *

Exercise

Never1-2 days3-4 days5+ days

Eating following a diet

I have a loose dietI have a strict dietI don't have a diet plan

Alcohol Consumption

Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day

Do you smoke or vape?

NoYes

Include other important comments regarding your Medical History, if nothing, type N/A*

I understand insurance is not accepted for services or medications at Revive Infusion & Injection Service *

I understand refunds will not be issued for any services or medications at Revive Infusion & Injection Services*

I understand that it is my responsibility to follow up with Revive Infusion & Injection Services either in clinic, via telehealth, or asynchronous visits( example texting and phone calls)on a regular basis. I will not adjust my dose without approval and consent from my provider. I will text any questions or concerns to 814-433-2632 please initial and date as acknowledgement.*

Informed Consent and Clinical Policies for Hormone Replacement Therapy (HRT) and Bioidentical Hormone Replacement Therapy (BHRT)

1. Acknowledgment of Specialized Care

I acknowledge that I am here for specialized care, including hormone replacement therapies for both men and women, such as testosterone replacement, bioidentical hormone therapies (estrogen, progesterone), and related hormone restoration treatments.

2. Patient Responsibilities for Medication Administration

I understand that I am responsible for safely administering the hormones and/or medications prescribed to me at home, including testosterone, estrogen, progesterone, DHEA, or other supplements as applicable. I agree to follow the prescribed dosages and frequencies and to promptly communicate any concerns to my provider.

3. Payment and Insurance Policies

Payment: Services are paid for at the time of each visit. Monthly medication refills are managed with an option for automatic billing. Without automatic billing, it is my responsibility to contact the office for refills, which will be invoiced via email.

Insurance: Health insurance is not accepted for these services.

4. Lab Testing and Monitoring

I am responsible for obtaining initial and followup labs through the designated lab service. Lab fees are separate from monthly medication management. Regular labs are essential for monitoring safety, and medication refills may not be issued without updated labs.

5. Primary Care and Specialized Treatment Disclaimer

I certify that I am under the regular care of a primary care provider or a specialist for any other medical conditions I may have or develop. I understand that hormone replacement therapy at Revive Infusion & Injection Services is a specialized service and does not replace comprehensive primary care.

6. Liability and OffLabel Use Acknowledgment

I have reviewed the risks associated with hormone restoration and replacement therapies, including testosterone, estrogen, and progesterone. I understand that these treatments may be considered offlabel and are not always FDAapproved for the specific conditions prescribed. I acknowledge that my treatment is at the provider’s discretion and agree that the anticipated benefits outweigh these risks.

7. Experimental and Anecdotal Treatment Acknowledgment

I understand that some hormone replacement treatments, including testosterone therapy and bioidentical hormone therapy with estrogen and progesterone, may be considered experimental or based on anecdotal evidence. I acknowledge that these treatments may not be deemed medically necessary by other providers or covered by insurance, and I agree to proceed with an informed understanding of these factors.

8. Medical FollowUp

If I experience side effects or become unwell, I agree to consult my primary care provider or seek urgent care. Consistent followup appointments are necessary to continue treatment safely, and Revive Infusion & Injection Services reserves the right to modify or discontinue treatment if needed.

9. Consent for Bloodwork and Evaluation

I consent to initial and followup blood work as recommended by my provider to monitor hormone levels, including testosterone, estrogen, progesterone, and related markers. Regular testing is necessary to ensure safe and effective treatment adjustments.

10. Gender Inclusive Care

I understand that hormone replacement therapy provided by Revive Infusion & Injection Services is inclusive of both male and female hormone health needs, addressing andropause in men, perimenopausal and menopausal symptoms in women, and related hormone imbalances.

11. Informed Consent and Voluntary Treatment Request

I have been informed of the risks, benefits, and potential complications of hormone replacement therapy, including possible side effects. I understand these and consent to treatment. I voluntarily request hormone replacement therapy and other treatments at Revive Infusion & Injection Services, even if my hormone levels may be within normal ranges as per general medical guidelines.

12. Preventive Care Responsibility

I understand that Revive Infusion & Injection Services LLC is not responsible for preventive care services (e.g., prostate screenings, pap smears, colonoscopies). I will ensure that my primary care provider oversees these screenings and agree to provide results to Revive as needed for safe and effective treatment.

Attestation: I have read and accept the above clinical policy and informed consent documents*

YesNo

Signature*

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General Information

Medical History