Membership Cancellation Request

Membership Cancellation Request

Submit your request to cancel your membership and confirm your understanding of next steps and care changes.
Full Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Please review and acknowledge each statement below:
I confirm I have read and understood all of the statements above
If you are currently using testosterone, please note that testosterone requires ongoing clinical monitoring and some side effects may be irreversible. You have been advised to discontinue testosterone when your care with us ends, unless another qualified healthcare provider has assumed responsibility for prescribing and monitoring your treatment.
Reason for cancellation
What made scheduling or communication difficult?

Other
Have you contacted your provider or checked the pharmacy section of the Member Hub about this?
In the last 2 months, have you requested a treatment plan review from your provider? Your membership includes the ability to have your treatment reviewed at any time by completing the symptom tracker in the Member Hub.
Would you like to have your treatment plan reviewed before your membership ends?
If you’re still having symptoms, you can request a treatment plan review before your membership ends. You do not need to wait for a scheduled visit. Complete the symptom tracker in the Member Hub and select Provider Review, and your provider can review your symptoms and recommend adjustments or other options if appropriate.
Pharmacy issues are often fixable

A lot of medication problems (cost, pharmacy stock, how to use it, side effects) can be solved without changing your treatment plan. You can message your provider directly through the portal, or check the pharmacy section of the Member Hub for cash-pay/insurance options and troubleshooting. Your cancellation will still go through if you'd still like to proceed — this isn't required, just worth a look first.
Before you finalize this, you have another option: if you'd like your provider to take one more look at your treatment, you can complete your symptom tracker at www.menopauselouisiana.com/track instead of cancelling. Your provider will review it and follow up with recommendations. If you'd still prefer to cancel, go ahead and continue below — this is completely optional.
Before you go — a few things to know about transferring care

Many PCPs and general OB/GYNs don't specialize in menopause hormone therapy, and dosing or delivery methods that work well for one provider's approach may need to be adjusted by another. Some formulations can also be harder to source depending on the pharmacy your new provider uses. This doesn't mean your new provider can't help — just that titration and pharmacy logistics may look different than what you're used to here. If it would help, we're glad to send a summary of your current treatment to your new provider — just email info@menopauselouisiana.com.
Before you cancel, is there anything you were hoping would improve that hasn’t improved enough yet?
Optional
If you selected 'Other' above, please explain your reason for cancellation.
Is there anything else you would like us to know?
I have read and understand the information above and am requesting cancellation of my membership with The Menopause Clinic.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: