Membership Registration Form

Membership Registration Form

Complete your membership enrollment details and acknowledgments to activate ongoing care with The Menopause Clinic.
This form activates ongoing membership care. Educational information explains the treatment options discussed; specific medication selection, dosing, and monitoring occur after enrollment as part of individualized care with The Menopause Clinic.
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 understand that my provider and care team will communicate with me through the secure patient portal, and that notifications and care-team updates may be sent by email from info@menopauselouisiana.com, no-reply@optimantra.com, and support@optimantra.com, and by text message from 504-389-2078 (Spruce) and 504-291-6270 (account alerts). I agree to check portal messages regularly, to add these email addresses to my safe-sender list, and to allow text messages from these numbers so I do not miss important care information.
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.
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.
Medication education acknowledgment
I understand that specific medication options (such as estradiol gel versus patch), instructions, and potential side effects are reviewed after membership activation through educational materials (written and video when applicable) and provider communication, and that medication decisions occur within the context of ongoing care.
Lab work and baseline testing
I understand that lab testing may be recommended as part of my care, and that the cost of any lab work is separate from my membership and is my responsibility.
Baseline labs are also available if you would like them for your own information even when your clinician has not required them for treatment (this would have been discussed during your visit). Let us know if you would like baseline testing before starting. Please note: Because a true baseline has to be drawn before your first dose, choosing baseline testing before starting will hold your prescriptions until your draw is complete — usually a few days, depending on how soon you can get to the lab.
Would you like baseline lab testing before starting?
Hormone therapy expectations
I understand that hormone therapy is a gradual process, not an immediate or one-time fix. It may take weeks to months to find the right treatment and dose for me, adjustments are often necessary because responses vary, and symptom improvement is evaluated over time. I agree to follow my provider's instructions, communicate how I'm feeling, and discuss any questions or concerns with my provider before making changes to my treatment.
Scope of care and emergencies
I understand that The Menopause Clinic provides non-emergency, outpatient care and does not provide urgent or emergency services. In a medical emergency, I will call 911 or go to the nearest emergency room.
Continuing your preventive and primary care
I understand that The Menopause Clinic provides specialty menopause and hormone care and is not my primary care provider or OB-GYN. I am responsible for continuing routine preventive care with my own primary care provider and OB-GYN, including age-appropriate screenings such as mammograms, cervical cancer screening (Pap tests), colon cancer screening, bone density testing when indicated, and routine checks such as blood pressure and cholesterol. I understand that my membership does not replace this care, and I agree to keep these screenings current with my other providers.
Hormone therapy and pregnancy
I understand that hormone therapy for perimenopause and menopause is not a form of birth control and does not prevent pregnancy. I understand that if I am perimenopausal, I may still be able to become pregnant — even if my periods are irregular or I am taking hormone therapy — until menopause is confirmed (generally 12 consecutive months without a period, or as determined by my provider). I understand that if I need contraception, I am responsible for using a separate, appropriate method, and I agree to discuss my contraceptive needs with my provider.
How would you like to begin?
If you are starting treatment now, confirm the pharmacy where you would like your prescriptions sent.
Pharmacy name
Pharmacy location (specific street address and city)
Pharmacy phone (if known)
If estradiol therapy is recommended, I prefer:
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.
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
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Membership Registration Form

Reviewing your treatment information

How my provider will communicate with me

Where I am located during care

Telehealth consent

What's included in your care

Monthly cost and billing authorization

Cash-pay practice (no insurance billing)

Medication education acknowledgment

Lab work and baseline testing

Hormone therapy expectations

Scope of care and emergencies

Continuing your preventive and primary care

Hormone therapy and pregnancy

Signature and confirmation