• New Patient Intake form

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Past Medical History

  • Do you have or have you ever been diagnosed with any of the following? (Check all that apply)*
  • Any past surgeries or hospitalizations?*
  • Do you have any known allergies (medications, food, etc.)?*
  • Preferred contact method?*
  • Preferred pronoun?*
  • Marital status*

  • Hormone & Peptide Therapy Goals

  • What are your primary health and wellness goals? (Check all that apply)*
  • Have you previously used hormone or peptide therapy?*

  • Lifestyle & Health Habits

  • How would you describe your diet?*
  • How often do you exercise?*
  • Do you smoke?
  • Do you drink alcohol?
  • Any known allergies to medications?*
  • Any known food or environmental allergies?*
  • Are any of your allergies life threatening?*
  • Has anyone in your family been affected by any of the following. Please check all that apply and (Mother, Father, Grandparents, Siblings, Children)
  • Sleep disturbance*
  • Fatigue*
  • Exposure to toxic chemicals*
  • Iron deficiency anemia*
  • Headaches or migraines*
  • Difficulty concentrating*
  • Head injury*
  • Frequent colds*
  • Sinus congestion or infections*
  • Mouth sores*
  • Dental/gum infections*
  • Cracked lips*
  • Recent changes in vision*
  • Dry eyes*
  • Acne*
  • Eczema*
  • Dry skin*
  • Easy bruising/bleeding*
  • Skin rashes*
  • Stomach pain and or/ cramps*
  • Acid reflux / heartburn*
  • Constipation*
  • Loose stools or diarrhea*
  • Bowel Movement Daily*
  • Abdominal bloating or gas*
  • Nausea or vomiting*
  • ADD / ADHD*
  • Food cravings*
  • Mood swings or mood disorders*
  • Depression*
  • Anxiety/nervousness*
  • Heart disease*
  • High blood pressure*
  • Heart palpitations*
  • Cold hands and feet*
  • Varicose veins*
  • Swelling of hands and feet*
  • Chronic Cough*
  • Asthma*
  • Shortness of breath*
  • Sleep apnea*
  • Seizures*
  • Numbness and tingling*
  • Loss of balance*
  • Joint pain or stiffness*
  • Neck/back pain*
  • Muscle weakness*
  • Muscle spasms or cramps*
  • Osteopenia/osteoporosis*
  • Burning or pain during urination*
  • Frequent urination at night*
  • Frequent urination at night*
  • Bladder infections*
  • Low libido*
  • Easy weight gain*
  • Hair loss*
  • Heat or cold intolerance*
  • Thyroid problems*
  • Blood sugar problems*
  • Contraceptive use
  • Absent periods
  • Irregular cycle
  • PMS
  • Heavy bleeding or spotting between cycles
  • Cervical Dysplasia/ HPV
  • Yeast Infections
  • Endometriosis
  • PCOS
  • Uterine fibroids
  • Difficult menopause - hot flashes, night sweat
  • Vaginal dryness
  • Infertility
  • History of Miscarriage
  • Recent changes in breasts
  • Nipple discharge
  • Date of last PAP exam
     - -
    2 digit month, 2 digit day, 4 digit year
  • History or abnormal PAP exam
  • Prostate problems
  • Erectile dysfunction
  • Use of Viagra
  • Infertility
  • Difficult urination
  • Do you exercise?*
  • How many alcoholic drinks per week?*
  • Do you smoke?*
  • Do you use recreational drugs?*
  • Rate your current stress level(5 being the highest)*
  • Do you eat fast food*
  • Do you eat out (not fast food)*
  • How many cups of coffee do you drink per day?*
  • How willing are you to change your eating habits to reach your goal?*

  • Valid Drivers License/ID

    Please upload the front and back of a valid license/ID
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  • Lab work upload

    Must be 2 months old or newer. If your current lab panel is greater than 2 months old, please text us at (727) 361-9873.
  • Do you have recent bloodwork that is 2 months old or newer?*
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  • If your current lab panel is greater than 2 months old, please text us at (727) 361-9873 so our staff can reach out to you and begin the easy process of getting your labs done!

    Lab Panels must include the following: CBC, CMP, estradiol, total testosterone (LCMS), free testosterone, SHBG, Lipid panel, Cortisol AM, Insulin, PSA, TSH, T3 uptake, free T3, reverse T3, free T4, free T4 index, T4 total, Thyroid peroxidase, IGF-1 and Thyroglobulin antibodies.

  • Have you had a physical this year?*
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  • Do you have a Primary care provider (PCP) or specialty doctor?*
  • Do you currently have or had any of the following conditions that you are being treated for? Diabetes, thyroid condition, cancer, or past cancer*
  • If yes, please specify the condition.
  • Do you acknowledge that a doctor's release is required to begin hormone therapy at the time of consultation, and that the release confirms the management of your condition and approval to start hormone therapy?

  • Informed Consent
     
    I understand that the medications that will be discussed with the Vivo HRT medical staff are of an elective nature, and never to be used in replace of medical evaluation through a qualified primary care physician for the treatment of a life threatening illness. I understand that there are risks to all medications including medications for Hormone Replacement Therapy. The risks associated with taking hormones include but are not limited to the possibility of an increased risk of cancer, blood clotting, stroke or heart attack. I accept and understand these risks and feel comfortable discussing these issues with the Vivo HRT team, and I wish to proceed with consultation and care. I also attest that I will not withhold medical information from the Vivo HRT team. I understand that my provider will do everything he/she knows to decrease and minimize all risks of HRT, and I agree to follow the ultimate advice, protocols, and recommendations of my Vivo HRT team. I understand that Hormone Replacement Therapy is very individualized and that there are no guarantees that these measures will be effective and I am participating in this therapy with that understanding. I accept all the risks and unknowns of taking hormone therapy and wish to have my provider consult, diagnose, prescribe, and guide me through this therapy for me.


    HIPAA Compliance Patient Consent Form
     
    Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or health care operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: 1. Protected health information may be disclosed or used for treatment, payment, or healthcare operations. 2.The practice reserves the right to change the privacy policy as allowed by law. 3. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. 4. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. 5. The practice may condition receipt of treatment upon execution of this consent.

     

    Acknowledgment:

    By signing below, you acknowledge that you have read and understood the details of the yearly membership fee. You agree to the collection of this fee at the time of your first medication refill.

  • Consent is not a condition of purchase. See our Privacy Policy and Terms and Conditions.

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