Hormone Replacement Therapy (HRT) Intake Form

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Please Complete the Form to the Best of your Knowledge- the purpose of this form is to guide our conversation during our virtual consultation

Informed Consent 

Patients considering HRT will be informed about:

• Expected benefits and limitations
• Possible risks (blood clots, cancer risks, cardiovascular effects, etc.)
• Alternatives (non-hormonal therapies, lifestyle changes)
• Need for ongoing monitoring

☐ By submitting this form, it is understood that this form is for the initial screening and does not guarantee eligibility for HRT.