Healthcare Hormone Support Form

Healthcare Hormone Support Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Tobacco Use:    Alcohol Use:

Hormone Therapy History

Have you previously received hormone therapy?   Yes No

Clinical Screening — Check All That Apply

Check conditions that are present or history of:

History of blood clots (DVT/PE)    Stroke / TIA    Coronary artery disease / MI

Active liver disease    History of breast cancer    Uncontrolled hypertension

Are you pregnant, breastfeeding, or trying to conceive? Yes    No

Risks, Benefits, and Alternatives

I understand that hormone therapy may provide benefits related to symptom relief and physiological changes, but also carries risks. Serious risks include increased risk of venous thromboembolism (blood clots), stroke, myocardial infarction, worsening of liver disease, and potential influence on hormone-sensitive neoplasms. Common side effects may include mood changes, changes in libido, fluid retention, and changes in laboratory values. I have been informed of reasonable alternative treatments, including non-hormonal options, and agree that no guarantees have been made regarding outcome.

I acknowledge I have had the opportunity to ask questions and that the provider has explained the intended benefits, material risks, potential side effects, and reasonable alternatives. I understand I may withdraw consent at any time and discontinue treatment, subject to medical advice about safe discontinuation.

Monitoring, Testing and Prescription Policies

I consent to necessary baseline and follow-up laboratory monitoring, including but not limited to liver function tests, lipid profile, hormone levels, complete blood count, and metabolic panel, as ordered by my provider. I understand labs are required prior to initiating therapy and periodically thereafter; treatment may be delayed or modified based on results.

Prescriptions will be issued in accordance with clinical guidelines and may be limited to quantities and refill intervals consistent with safe practice. I understand that prescriptions may be modified or discontinued if adverse effects, contraindications, or safety concerns arise.

Release of Information & HIPAA Authorization

By signing below I authorize my healthcare provider and their staff to use and disclose my protected health information related to hormone therapy and associated care to the extent necessary for treatment, payment, and healthcare operations. I authorize release of results and treatment information to the following persons (if any):

This authorization will remain in effect until the expiration date provided below or until revoked in writing. I understand that revocation will not apply to disclosures already made in reliance on this authorization. I acknowledge that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations.

Acknowledgments and Consent

I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that omission of relevant medical history may increase the risk of harm. I consent to medical evaluation and treatment for hormone therapy and to the ordering of prescriptions and laboratory tests as clinically indicated.

I understand that if I become pregnant or plan to become pregnant I must immediately notify my provider and that hormone therapy may be contraindicated during pregnancy or breastfeeding.

I consent to voicemail, text, and email communications regarding appointment reminders and test results at the contact information provided. I understand standard messaging is not completely secure and accept associated risks.

I consent to the recommended laboratory monitoring and understand that failure to obtain testing may result in modification or discontinuation of therapy.

I acknowledge receipt of the provider's privacy practices and understand my rights regarding protected health information.

Provider Information (for clinic use)

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