Progesterone Questionnaire

Full Name

First NameLast Name

E-mail Address

example@example.com

Contact Number

Format: (000) 000-0000.

Mailing Address

Street Address

Street Address Line 2

CityState

Post Code

We are only licensed to ship prescriptions to Utah right now - but we're expanding quickly! If you are from a different state and interested, fill out this form and we'll let you know when we are able to ship to you.

Sex at Birth

Date of Birth

DayMonthYear

Check all that apply in the last 3-6 months:

Are you currently:

Have you ever been diagnosed with?

Are you currently taking any hormone therapy (estrogen, testosterone, DHEA, progesterone)?

If yes, list dose and form:

Are you currently pregnant or breastfeeding?

Have you had a hysterectomy or ovary removal?

Have you ever had any of the following:

If you marked any of the above, please provide details (diagnosis, year, current status, treatments, etc).

What medications are you currently taking (prescriptions, OTC, supplements)?

Do you have any allergies?

Allergen and symptoms

Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?

Please provide details.

Have you had recent hormone labs?

If yes, please list results:

Consent

I understand the risks and benefits of progesterone therapy have been explained to me.

I consent to share this information with the prescribing provider and compounding pharmacy.

Signature

What is your primary goal with hormone therapy?

How did you hear about us?

Referral:

My Products

Progesterone Package

- Complete symptom and health history review, personalized progesterone therapy plan, first month prescription, home delivery, and patient support from our team.

$199.00 Quantity

Total

Debit or Credit Card
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