This form is for patients who wish to enroll in the optional Monthly Hormone Care Plan after their initial consultation.
Enrollment is not required and may be started or stopped at any time.

What’s Included
The Monthly Hormone Care Plan may include:

• Prescription refills when appropriate
• Dose adjustments between visits
• Secure messaging
• Lab review and ongoing clinical oversight
• There are no per-refill or per-message fees while enrolled.

Cost & Billing
The Monthly Hormone Care Plan is $79 per month.

Billing is automatic and recurs monthly using the payment method on file. You may cancel at any time; cancellation takes effect at the end of the current billing cycle.

Medications and laboratory costs are not included.

Alternative Option
Enrollment is optional. Patients may instead continue with visit-based, pay-as-you-go care, including follow-up visits and refill requests billed individually.

Consent
By submitting this form, I request enrollment in the Monthly Hormone Care Plan and authorize recurring monthly billing. I understand that enrollment does not guarantee medication prescriptions and that all care decisions are based on medical judgment and patient safety.