Customer Information Form Step 1 of 8 12% Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Ensuring that our patients' information is safe and secure is one of our top priorities. This form is SHA-256 with RSA Encrypted. Patient Authorization for Delivery of MedicationsFirst Name(Required) First Last Name(Required) Last 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. If your state is not licensed by any of the compounding pharmacies, we are allowed to sign for the order and send it to the patient. Any orders delivered damaged or incomplete must be reported to Premier Alternative Medicine, referred to as PAM, within 24 hours of delivery, and the pictures of damaged package/product must be sent to info@premieralternativemeds.com. 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.Consent I agree to the privacy policy. 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.Referred By(Required) New to HRT/TRT, or transferring? New Patient Transferring Who are you transferring from? Date of Birth MM slash DD slash YYYY General information about the participant:Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Secondary PhoneIs it also OK to text you?(Required) Yes No No worries, we don't spam! Email(Required) Marital Status(Required)MarriedDivorcedSingleWidowedOtherSex(Required)MaleFemale Please provide information about any current primary care provider below.Doctor/Other Name First Last Physician Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Physician PhoneMay I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary? Yes No What is (are) your purpose (s) for participation in this HRT Program?(Required) To determine my current level of health and to receive recommendations for an HRT program. Other (please explain below) Explain what is (are) your purpose (s) for participation in this HRT Program?Present Medical History Has a doctor ever said your blood pressure was too high Do you ever have pain in your chest or heart Are you often bothered by a thumping of the heart Does your heart often race Extra heartbeats or skipped beats Are your ankles often badly swollen Do cold hands or feet trouble you even in hot weather Has a doctor ever said that you have or have had heart trouble, an abnormal electrocardiogram (ECG or EKG), heart attack or coronary Do you suffer from frequent cramps in your legs Do you often have difficulty breathing Do you get out of breath long before anyone else Do you sometimes get out of breath when sitting still or sleeping Has a doctor ever told you your cholesterol level was high Has a doctor ever told you that you have an abdominal aortic aneurysm Has a doctor ever told you that you have critical aortic stenosis Check those questions to which you answer yes (leave the others blank). Do you now have or have you recently experienced: Chronic, recurrent or morning cough Episode of coughing up blood Increased anxiety or depression Problems with recurrent fatigue, trouble sleeping or increased irritability Migraine or recurrent headaches Swollen or painful knees or ankles Swollen, stiff or painful joints Pain in your legs after walking short distances Foot problems Back problems Stomach or intestinal problems, such as recurrent heartburn, ulcers, constipation or diarrhea Significant vision or hearing problems Recent change in a wart or a mole Glaucoma or increased pressure in the eyes Exposure to loud noises for long periods An infection such as pneumonia accompanied by a fever Significant unexplained weight loss A fever, which can cause dehydration and rapid heartbeat A deep vein thrombosis (blood clot) A hernia that is causing symptoms Foot or ankle sores that won't heal Persistent pain or problems walking after you have fallen Eye conditions such as bleeding in the retina or detached retina Cataract or lens transplant Laser treatment or other eye surgery Additional Comments Do you have: Menstrual period problems Significant childbirth - related problems Urine loss when you cough, sneeze or laugh Date of last pelvic exam/pap smear MM slash DD slash YYYY Additional Comments regarding female specific sexual based health historyPlease use this area to add additional comments regarding female specific sexual based health history.List any prescription medications you are now takingPrescription Medicines Add RemovePlease use the plus button to the right to add all medicine you're currently taking.List any self-prescribed medications, dietary supplements, or vitamins you are now takingOther supplements Add RemovePlease use the plus button to the right to add all medicine you're currently taking.Date of last complete physical examination MM slash DD slash YYYY Outcome of last physical exam Normal Abnormal Never Can't Remember/Other Date of last chest X-ray MM slash DD slash YYYY Outcome of last chest X-Ray Normal Abnormal Never Can't Remember/Other Date of last electrocardiogram (EKG or ECG) MM slash DD slash YYYY Outcome of last (EKG or ECG) Normal Abnormal Never Can't Remember/Other Date of last dental checkup MM slash DD slash YYYY Outcome of last dental checkup Normal Abnormal Never Can't Remember/Other Past Medical History Rheumatic Fever Heart murmur Diseases of the arteries Varicose veins Arthritis of legs or arms Diabetes or abnormal blood-sugar tests Phlebitis (inflammation of a vein) Dizziness or fainting spells Epilepsy or seizures Stroke Diphtheria Scarlet Fever Infectious mononucleosis Nervous or emotional problems Anemia Thyroid problems Pneumonia Bronchitis Asthma Abnormal chest X-ray Other lung disease Injuries to back, arms, legs or joint Broken bones Jaundice or gallbladder problems Heart attack (if yes, enter years below) Check those questions to which your answer is yes (leave others blank). How many years ago did you have heart attack? Additional comments about past medical history Low Testosterone symptoms Sexual dysfunction Body fatigue or weakness Depression or anxiety Increased body fat Increased irritability Check box that pertains to you.Sexual dysfunction symptoms Inability to get an erection Difficulty maintaining an erection Reduced sex drive Check box that pertains to you.Anabolic necessity symptoms Have you lost weight or muscle tissue from surgery, trauma, or depression Do you suffer from anemia Difficulty gaining or maintaining weight Do you have significant joint pain Do you suffer muscle soreness and fatigue Check the box that pertains to you. Low HGH symptoms High levels of body fat Anxiety and depression Decreased sexual desire Overall fatigue Muscle atrophy Hard to fall asleep Reduced ability to stay asleep Check the box that pertains to you. Difficulty losing weight symptoms Metabolic syndrome/caffeine doesn't work anymore Insulin resistance Large waistline Increased blood pressure High blood sugar levels High LDL levels Check the box that pertains to you. Low thyroid symptoms Overall fatigue Get cold easily, even when it's hot Excessive hair loss Are you very irritable Do you feel sluggish Gain body fat easily Check the box that pertains to you. Upload ID File(Required)Max. file size: 64 MB.Upload Labs FileMax. file size: 64 MB.
