Hormone Consultation Referral Form
Referring Physician Details
Name
*
First Name
Last Name
NPI
*
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Details
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select if there are any specific labs you would like us to perform.
Pharmacist & Patient Choice
Estradiol, saliva
Progesterone, saliva
Testosterone, saliva
Cortisol, saliva (am, noon, pm, hs)
DHEA-S
Vitamin D2, D3, blood spot
SHBG, blood spot
PSA, blood spot
LH, blood spot
C-reactive protein, blood spot
FSH, blood spot
Hemoglobin A1c (A1C now Pro)
TSH, Free T4, Free T3, TPOab
Sex Steroid Metabolites, dried urine
Relevant details about the patient's condition
Please upload or fax (806-839-3170) any relevant lab work from your office, if available.
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