Initial Female Hormone Evaluation

New Patient Visits:

Initial BHRT & Nutritional Consultation 1 hour $150.00

BHRT Follow-up or review of labs:
*If your visit extends past your appointment time you will be billed accordingly.
15 minute visit (1-15 minutes) $30.00
30 minute visit (16-30 minutes) $60.00
45 minute visit (31-45 minutes) $90.00

Appointment Cancellation Fee: (when less than 24 hours’ notice is given)
New patient appointment $75.00
Follow-up appointment $20.00

Saliva testing: (Other options available at variable prices, most common listed below)
Female/Male Saliva Profile 1 (E2, Pg, T, DHEAs, Cx1) 130.00

Phone Consultations
Initial BHRT Clinical Consultations as well as follow up visits may be scheduled as a phone consult to accommodate those who may be out of town or unable to travel to the pharmacy. The Clinical Pharmacist bills phone calls made to patients. Please be sure to allow the staff to answer your questions first before requesting to speak with the clinical pharmacist to avoid unnecessary fees. If the staff is unable to help you, or determines a referral is needed to the Clinical Pharmacist, an office visit or phone consult with be scheduled. Bremo Pharmacy requires a credit card to keep on file for appointment cancellation fees. All fees are due at the time of service.

Acknowledgement Statement

Today's Date

Date

Name

First NameLast Name

Birthdate

Date

Age

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Height

Weight

Desired Weight

Do you use tobacco?

How often and how much?

Do you use alcohol?

How often and how much?

Do you use caffeine?

How often and how much?

Do you exercise?

How often and how much?

Please list any food allergies and describe the reaction that occured.

Please list any drug allergies and describe the reaction that occured.

Please list any other allergies and describe the reaction that occured.

Do you take any over the counter medications?

Please list non-prescription medications that you are taking (including vitamins, herbals, and supplements) Click + to add each medication.

Medical Conditions/Diseases: Please list any conditions/disease that you have been diagnosed with or suffer from. (Examples include: Heart disease, high blood pressure, depression, ulcers, arthritis, insomnia, etc).

Do you take any prescription medications?

Please list current prescription medications (including hormones). Click + to add each medication.

Have you previously taken hormones?

Please list hormones previously taken

Have you ever used oral contraceptives?

If you experienced any problems, please describe

How many pregnancies have you had?

How many children?

Any interrupted pregnancies?

If yes, please explain

Have you had a tubal ligation?

Date of surgery

Date

Have you had a hysterectomy?

Date of surgery

Date

Reason

Do you ovaries remain?

Do you have a family history of any cancers? Please list the family member(s) and type of cancer

Do you have a family history of osteoporosis? Please list the family member(s)?

Have you ever had a mammography?

When was your last mammography?

What was the outcome of your mammography? (ex: normal, abnormal, other-please explain)

Have you ever had a PAP Smear?

When was your last PAP Smear?

What was the outcome of your PAP Smear? (ex: normal, abnormal, other-please explain)

Have you ever had a bone density test?

When was your last bone density test?

What was the outcome of your last bone density test?

What age did your period start?

How many days is/was your cycle (Example: 28)

Is/was your menstrual flow heavy or light?

Any clots?

Have you ever had what YOU would consider to be abnormal cycles

Explain

When was your last period?

How many days did it last?

Do you or have you ever suffered from Premenstrual Syndrome (PMS) symptoms?

Explain

Please rate your current symptoms of hot flashes.

Please rate your current symptoms of night sweats.

Please rate your current symptoms of vaginal dryness.

Please rate your current symptoms of incontinence.

Please rate your current symptoms of bleeding changes.

Please rate your current symptoms of fibrocystic breast.

Please rate your current symptoms of weight gain.

Please rate your current symptoms of fluid retention.

Please rate your current symptoms of dry skin/hair.

Please rate your current symptoms of hair loss.

Please rate your current symptoms of anxiety.

Please rate your current symptoms of depression.

Please rate your current symptoms of mood swings.

Please rate your current symptoms of irritability.

Please rate your current symptoms of headaches.

Please rate your current symptoms of breast tenderness.

Please rate your current symptoms of cramps.

Please rate your current symptoms of difficulty falling asleep.

Please rate your current symptoms of difficulty staying asleep.

Please rate your current symptoms of fatigue.

Please rate your current symptoms of loss of memory.

Please rate your current symptoms of foggy thinking.

Please rate your current symptoms of acne.

Please rate your current symptoms of arthritis.

Please rate your current symptoms of decreased sex drive.

Please rate your current symptoms of harder to reach climax.

Please rate your current symptoms of stress.

Please list any other symptoms you are experiencing.

What are your goals for taking Hormone Replacement Therapy?

Doctor we should contact for requests for hormone therapy

Doctor's Phone Number

Format: (000) 000-0000.

Doctor's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please let us know how you heard about our services (check all that apply):

Please upload any relevant lab work, especially hormone levels that you have recently obtained.

Disclamer for BHRT Consultation Services:

Information provided is not intended to diagnose, treat, cure, or prevent any disease, condition,or malady. No warranty is made or given that ANY information is complete and/or accurate and no warranty is given that there may not be a contrary view to any of the material that is hereby provided. The information is not intended to be nor is it implied that to be a substitute for professional medical advice. One should always seek the advice of their physician or other qualified health care provider before beginning any new treatment for any of the conditions, diseases, or maladies in relation to which advice is sought. Questions related to such treatment should be directed to professional health care providers.

Signature

CONFIDENTIAL FEMALE HORMONE EVALUATION

Bremo Pharmacy Consultation Fees Schedule

Disclaimer for BHRT Consultation Services