Membership Registration Form

Membership Registration Form

Complete your membership enrollment details and acknowledgments to activate ongoing care with The Menopause Clinic.
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Takes about 5–8 minutes — you'll see your progress as you go.
At a glance
Before you get started, here's a quick preview of what you're agreeing to below:
- We'll reach you by email (info@menopauselouisiana.com, Optimantra) and text (504-389-2078, 504-291-6270) — please allow these senders
- Your Member Hub (menopauselouisiana.com/member-hub) is where you'll find education, refill requests, and your ongoing care resources
- Your treatment plan arrives as your first portal message, within 24 business hours of signup
- Check-ins matter — your provider needs your symptom updates to adjust your care, and we ask for a response within one week
- Cancel anytime by emailing us at least 10 days before your next billing date — no long-term contract
The details for each of these are below.
Reviewing your treatment information
I understand that all of my treatment information — including educational materials, medication options (such as estradiol gel versus patch), dosing instructions, potential side effects, and monitoring guidance — is provided through my secure patient portal and in my Member Hub at www.menopauselouisiana.com/member-hub after my membership is activated. I understand it is important that I read all of this information carefully, that it remains available in the portal and Member Hub so I can return to it at any time, and that I am responsible for reviewing it before and during treatment. I understand these materials may be written or video, that medication decisions occur within the context of ongoing care with my provider, and that I will contact the clinic with any questions before starting.
How my provider will communicate with me

I agree to check the patient portal regularly and to allow messages from these senders so I don't miss anything important about my care or membership:
- Email: info@menopauselouisiana.com, no-reply@optimantra.com, support@optimantra.com — please add these to your safe-sender list
- Text: 504-389-2078 (Spruce — automated reminders, no reply needed) and 504-291-6270 (account alerts — please read these right away)
- Portal messages — this is where your provider sends clinical replies, including your treatment plan. Go to https://www.menopauselouisiana.com/member-hub to see everything in one place.
I understand it is my responsibility to keep my contact information (email, phone, and payment method) current, and to notify the clinic promptly if any of it changes.
I understand how my provider will communicate with me, and agree to keep my contact information current.
Where I am located during care
I confirm that I am physically located in the State of Louisiana at the time of every interaction with The Menopause Clinic — including video visits, secure portal messaging, phone or text communication, and in-person visits. I understand that my provider is licensed in Louisiana and can only provide care while I am physically present in Louisiana. I agree to notify the clinic before any interaction if I am located outside of Louisiana, and I understand that care cannot be provided at those times. All in-person visits take place at 700 Camp St Suite 203, New Orleans, LA 70130.
Telehealth consent
I consent to receiving care from The Menopause Clinic through telehealth, including video visits, secure portal messaging, and phone or text communication. I understand the benefits of telehealth, including convenient access to specialist care, as well as its limitations — that a remote visit is not the same as an in-person exam, that not every condition can be evaluated or treated by telehealth, and that my provider may determine an in-person visit or referral is needed. I understand the care I receive will follow the same professional and privacy standards as in-person care, that I may ask questions about telehealth at any time, and that I may withdraw this consent at any time.

What's included in your care
Your membership includes ongoing specialist care across two phases. ACTIVE CARE (Phase 1, first 4 months, $129/month): secure portal messaging with your clinician; structured symptom updates and medication response review; medication adjustments when clinically appropriate; prescription and refill management; lab guidance and lab review when needed; help navigating pharmacy issues and medication options; up to 2 optional video visits during Active Care. MAINTENANCE CARE (Phase 2, month 5 and beyond, $89/month): continued secure portal messaging with your clinician; ongoing prescription and refill management; dose review when symptoms change; lab review when needed; long-term hormone therapy planning; safety monitoring and annual care review; up to 1 optional video visit per membership year.
I understand what my membership includes, including the video visits listed above (up to 2 during Active Care and up to 1 per membership year during Maintenance Care). I understand that if I request a visit beyond what my membership includes, it is available for an additional fee — $50 for a video visit or $100 for an in-person visit — and that this additional fee applies only when a requested visit exceeds what is already included in my membership.
I understand that The Menopause Clinic does not replace my primary care provider, OB/GYN, or other healthcare providers. I am responsible for keeping up with recommended routine and preventive care, including appropriate cancer screenings. I understand that estrogen and progesterone do not cause cancer, but some cancers can be sensitive to hormones. If a hormone-sensitive cancer is already present, hormone therapy may potentially stimulate its growth. I agree to notify The Menopause Clinic of any new cancer diagnosis, abnormal screening result, unexplained bleeding, breast changes, or other significant change in my health
Monthly cost and billing authorization
Your membership cost: Active Care (months 1-4) $129 per month; Maintenance Care (month 5 onward) $89 per month; optional testosterone therapy add-on (if applicable) $20 per month with no additional visit fees. If you enroll within two weeks of your initial visit, your first-visit fee is credited toward your first month.
I understand my membership is billed monthly on a recurring basis, and I authorize The Menopause Clinic to charge the payment method I provide on that recurring cycle. I understand my membership cost is $129 per month for the first four months (Active Care) and then $89 per month beginning in month five (Maintenance Care), plus the testosterone add-on ($20/month) if I select it. I understand that if I enroll within two weeks of my initial visit, my first-visit fee is credited toward my first month's payment. I understand charges recur automatically until I cancel in writing by emailing info@menopauselouisiana.com at least 10 days before my next billing date; that no refunds are issued for partial billing cycles or unused time; that services may be paused if a payment is declined; and that I confirm I am the authorized user of the payment method provided.
Cash-pay practice (no insurance billing)
I understand that The Menopause Clinic is a cash-pay membership practice and does not bill insurance. I am responsible for my membership fees and any additional fees I incur. I understand a superbill is available on request that I may choose to submit to my insurer, and that reimbursement is not guaranteed.

Were you referred by a current patient? Let us know their name so you both receive a thank-you from us. You'll get $25 off your first month, and they'll get $25 off their next renewal at The Menopause Clinic. If you were not referred, please enter N/A.
I understand that the required next steps are available at menopauselouisiana.com/nextsteps, and I confirm that I will complete all steps listed there before treatment can begin.
Patient Identification UploadMedical clinics are required to verify patient identity to protect your privacy, keep your medical record accurate, and make sure prescriptions and treatment are provided to the correct person. Please upload a clear photo of a current government-issued photo ID.

Cancelof
Signature and confirmation
By signing below, I confirm that I have read and understood all of the above, that I am at least 18 years of age, that I am the authorized user of the payment method I have provided, and that the information I have given is accurate and complete.
Printed full legal name
Email address
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you have any trouble with this form, text 504-389-2078
After you submit, you'll be taken straight to your next step (setting up your patient portal) — don't close this tab until you see that page.
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