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Prometheuz HRT

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HRT/ED

Initiation Fee

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Labs are always local, no obligation, and $0 consultation fees!
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New Patient Intake Form

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Patient Authorization for Delivery of Medication

Ensuring that our patients' information is safe and secure is one of our top priorities. This form is SHA-256 with RSA Encrypted.

hereby authorize the clinic’s staff on duty to act on my behalf to accept medication delivery from the clinic’s dispensing physician and deliver my medications and refills to me as prescribed by my physician.

I understand that delivery of such medications can be picked up at the clinic or mailed to my provided address on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. Any orders delivered damaged or incomplete must be reported to Prometheuz Alternative Medicine; referred to as PAM within 24 hours of delivery and the pictures of damaged package/product must be sent to [email protected].

PAM is not financially responsible or liable for lost or stolen items once delivered. Once items have been scanned as delivered to the customer's address, it is up to the customer to report any missing or stolen packages to PAM within 24 hours of the delivery date.

Any packages returned for an INCOMPLETE/ INCORRECT address can be shipped again at the patient's expense.

No Guarantee of Services
We do not guarantee that any services or medications will be provided to you until you have undergone the full initial sign up process and physician’s examination. At the physician’s discretion only, you will be provided medications and/or services during your program at PAM.

PAM requires you to have an annual consultation with our provider and annual lab work is done. Lab work every 6 months is preferred but not required. Additional lab work can be requested by the provider at any time.

No Refund Policy
*PAM reserves the right to have NO RETURN and NO REFUND policy.

Informed Consent for Hormone Replacement Therapy

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA only for prescribed deficiencies. Using it for other symptoms or problems is considered “off-label” use, and the liability is on the patient, not the doctor. When hormone levels are brought back to “normal” for your age, there is much evidence that your overall health benefits. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment.

Current medical thinking is always changing, so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest thinking is. Please read the following and sign: I have discussed the reason for taking female sex hormones with my doctor and understand why he/she is prescribing them and the risks associated with taking hormones, including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different risks if I take any HRT medication.

I have discussed this risk and the reasons for taking them with my doctor. I understand that my doctor will do everything he/she knows to do to decrease and minimize the risks of HRT but that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my doctor prescribe them for me.

Enter the full name of the person who referred you to us. If none, how did you hear about us?
New to HRT/TRT of Transferring?
Use this area if you are transferring. Enter the name of the clinic or a doctor.
Date of Signing

Medical History and Screening Form

General Information

Participant

*** Any future address change must be submitted in writing to [email protected]

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Family Physician and/or Primary Health Care Provider

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May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?
Marital Status
Sex
What is (are) your purpose (s) for participation in this HRT Program?

Present Medical History

Check those questions to which you answer yes (leave the others blank).
Do you now have or have you recently experienced:
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Past Medical History

Check those questions to which your answer is yes (Leave other blanks).
Use this area to add years.
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Hormone Health:
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UPLOAD YOUR DOCUMENTS

To speed up the process the following is needed:

  • Your ID
  • Your Insurance Card (if you have one for the labs only)
  • Your labs no more than 6 months old (if you have it. For the labs only, please note we can accept only PDF format, no screenshots)
  • Smaller files will upload faster, please avoid sending large formats
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