Customer Information Form

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Patient Authorization for Delivery of Medications

First Name(Required)
Last Name(Required)

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
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.
New to HRT/TRT, or transferring?
MM slash DD slash YYYY
General information about the participant:
Name(Required)
Address(Required)
Is it also OK to text you?(Required)
No worries, we don't spam!
Please provide information about any current primary care provider below.
Doctor/Other Name
Physician Address
May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?
What is (are) your purpose (s) for participation in this HRT Program?(Required)
Present Medical History
Check those questions to which you answer yes (leave the others blank).
Do you now have or have you recently experienced:
Do you have:
MM slash DD slash YYYY
Please use this area to add additional comments regarding female specific sexual based health history.
List any prescription medications you are now taking
Prescription Medicines
 
Please 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 taking
Other supplements
 
Please use the plus button to the right to add all medicine you're currently taking.
MM slash DD slash YYYY
Outcome of last physical exam
MM slash DD slash YYYY
Outcome of last chest X-Ray
MM slash DD slash YYYY
Outcome of last (EKG or ECG)
MM slash DD slash YYYY
Outcome of last dental checkup
Past Medical History
Check those questions to which your answer is yes (leave others blank).
Low Testosterone symptoms
Check box that pertains to you.
Sexual dysfunction symptoms
Check box that pertains to you.
Anabolic necessity symptoms
Check the box that pertains to you.
Low HGH symptoms
Check the box that pertains to you.
Difficulty losing weight symptoms
Check the box that pertains to you.
Low thyroid symptoms
Check the box that pertains to you.
Max. file size: 64 MB.
Max. file size: 64 MB.