• Anti-Aging Ultra Cream Request

    Share your details, skin goals, and health history so your provider can determine whether this compounded cream is a safe fit for you.

  • About you

  • What happens next: your provider reviews your information. If you are approved, you'll get a text with a billing link from 504-389-2078.
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Current TMC member?

  • Your skin goals

  • What would you most like to improve?*
  • Do you currently have any of the following on your face? Check all that apply.*
  • Upload a File
    Drag and drop files here
    Choose a file
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  • Health history

  • Ever had breast, uterine/endometrial, ovarian, or any other hormone-sensitive cancer?*
  • Currently taking tamoxifen, an aromatase inhibitor, or other endocrine/anti-hormone therapy?*
  • Any vaginal bleeding that hasn’t been evaluated by a clinician?*
  • Ever had a blood clot, stroke, or been told you have a clotting disorder?*
  • Do you have active liver disease?*
  • Are you pregnant, trying to get pregnant, or breastfeeding?*
  • Ever had a meningioma?*
  • Has a close family member had breast or ovarian cancer, or are you a carrier of a BRCA or other high-risk gene?*
  • Ever had a severe allergic reaction or a known allergy to progesterone, estrogen, azelaic acid, or vitamin C?*
  • Do you have an autoimmune condition that flares with your menstrual cycle, or have you been told you react to your own progesterone?*
  • Are you currently using any hormone therapy?*

  • Acknowledgements

  • Acknowledgement statements*
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: