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Full Name *

Referral Code

Date / Time

Date

Time

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Date of Birth: *

Age:

Driver License # *

State of Issuance for DL

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone: *

Work Phone:

Email: *

May we contact you via E-Mail?

Yes
No

In Case of Emergency Contact: *

Relationship With Contact: *

Emergency Contact Phone Number: *

How were you referred to REVV? *

I smoke _____ cigarettes or cigars per day.

I drink _____ alcoholic beverages per week.

I consume _____ caffeinated products per week.

I do cardio _____ times per week.

I do weight training _____ times per week.

Any known drug allergies: *

Have you ever had any issues with local anesthesia (lidocaine or epinephrine)? If yes please explain, if no, ignore:

Medications Currently Being Taken:

Current Hormone Replacement Therapy:

Past Hormone Replacement Therapy:

Nutritional/Vitamin Supplements:

Surgeries, list all and when:

Last menstrual period (estimate year if unknown): *

Other pertinent information:

Medical Illnesses:

If Cancer what type and year?

Medical/GYN Exam date:

Mammogram date:

Bone Density Test date:

# of Pregnancies and Live Children:

Past Medical/Surgical History:

Birth Control Method

If other please state:

Depressive mood (feeling down/sad/lack of drive)

Selected Value: 1

1 being never 4 being SEVERE

Memory loss (forgetfulness)

Selected Value: 1

1 being never 4 being SEVERE

Mental Confusion (feeling in a mental fog)

Selected Value: 1

1 being never 4 being SEVERE

Decreased sex drive/libido (decreased desire for sex)

Selected Value: 1

1 being never 4 being SEVERE

Sleep problems (difficulty falling/staying asleep/wake up tired)

Selected Value: 1

1 being never 4 being SEVERE

Mood changes/irritability

Selected Value: 1

1 being never 4 being SEVERE

Tension

Selected Value: 1

1 being never 4 being SEVERE

Migraine/severe headache

Selected Value: 1

1 being never 4 being SEVERE

Difficult to climax sexually

Selected Value: 1

1 being never 4 being SEVERE

Bloating

Selected Value: 1

1 being never 4 being SEVERE

Weight gain

Selected Value: 1

1 being never 4 being SEVERE

Breast tenderness

Selected Value: 1

1 being never 4 being SEVERE

Vaginal dryness

Selected Value: 1

1 being never 4 being SEVERE

Hot flashes

Selected Value: 1

1 being never 4 being SEVERE

Night sweats

Selected Value: 1

1 being never 4 being SEVERE

Dry and wrinkled skin

Selected Value: 1

1 being never 4 being SEVERE

Hair is falling out

Selected Value: 1

1 being never 4 being SEVERE

Cold all the time

Selected Value: 1

1 being never 4 being SEVERE

Swelling all over the body

Selected Value: 1

1 being never 4 being SEVERE

Joint pain

Selected Value: 1

1 being never 4 being SEVERE

Other symptoms that concern you:

Consent for Hormone Replacement Therapy

Hormone replacement therapy is implemented to optimize hormone levels in the blood, helping to reduce symptoms associated with low levels of these hormones.

Many individuals have inadequate hormone levels despite technically normal blood tests. Some individuals suffering symptoms related to menopause or andropause or inability to lose weight may also benefit from these therapies. Hormone replacement therapy can be used to augment hormone levels in a number of conditions where diminished hormone levels are evident.

I understand that treatment with estradiol is FDA approved for menopausal symptoms, progesterone is FDA approved for endometrial hyperplasia, and testosterone is FDA approved for hypogonadism.

I acknowledge that estradiol, progesterone and testosterone may be prescribed off label for a variety of other reasons and symptoms.

I acknowledge that there are no guarantees or assurances made with respect to the benefit of the bio-identical hormone supplementation therapy prescribed for me.

I understand that I will be in charge of administering these hormones and supplements prescribed to me.

I will conform and comply with the recommended doses and methods of administration.

I understand that initial blood tests will be performed to establish my baseline hormone levels.

I agree to comply with requests for ongoing testing to assure proper monitoring of my hormone levels.

I agree to report to the medical provider any adverse reaction or problems that might be related to my hormone therapy.

I understand that with hormone supplementation there are possible risks and complications:

Estrogen Therapy: Estrogens are available in various forms including oral capsules, troches, patches, topical creams/gels, or pellets. Adverse reactions may include bloating, breakthrough bleeding, breast swelling and tenderness, fluid retention, weight gain, liver cysts, death (e.g.-from blood clots or cancer) and mood swings. High potency conjugated estrogens (e.g. Premarin), and perhaps even estradiol, have been associated with an increased risk of breast cancer and blood clots (the latter especially in smokers). Estriol may carry a lower risk of breast cancer and may even protect against breast cancer. Nonetheless, the whole area of estrogen replacement is undergoing further evaluation. Do not take estrogen if you have estrogen receptor-positive breast cancer. Alternatives to bioidentical estrogen include but are not limited to nutraceutical supplementation, acupuncture, and non-treatment.

Progesterone Therapy: Progesterone is available in various forms including oral capsules, troches, vaginal or rectal suppositories, and topical creams/gels, or pellets. Progesterone therapy may be sedating, so it is recommended to coordinate dosing with the sleep cycle. Adverse reactions may include bloating, breakthrough bleeding, missed menstrual cycles, breast swelling and tenderness, fluid retention, weight gain, sedation, and depression. Do not take progesterone if you have progesterone receptor positive breast cancer. Alternatives to bioidentical progesterone include but are not limited to nutraceutical supplementation, acupuncture and non-treatment.

Testosterone Therapy: Testosterone therapy is available in various forms including sublingual drops, troches, topical creams/gels, intramuscular injections, or pellets. Side effects may include acne, chronic priapism (persistent, abnormal erection of the penis), change in libido, angina or heart attacks, hirsutism (facial hair growth) and scalp hair loss, clitoral engorgement, voice changes, or water retention. Because it may improve insulin resistance in males, diabetics who use insulin should monitor glucose levels closely, as less insulin may be needed.Check with your physician before adjusting your dose of insulin. If using a formulation of testosterone that is applied to the skin, a local irritation may occur. ln women, excessive testosterone or DHEA doses could increase the risk of diabetes or facial hair. Testosterone therapy is contraindicated if you have a history of testicular or prostate cancer. Alternatives to bioidentical testosterone include but are not limited to nutraceutical supplementation, acupuncture and non-treatment.

After consideration of these risks I consent to treatment with hormones.

I have not been promised or guaranteed any specific benefit from the administration of this therapy.

I understand that the role of the medical provider is for hormone replacement only.

I agree that I am and will be under the care of another physician for all other medical conditions. Revv Health does not accept insurance for hormone therapy services and any associated lab work.

I, therefore, agree to pay for all services including laboratory, membership and/or medication charges myself, with the understanding that I will not be reimbursed by my insurance company. There are no exceptions.

I have read and understand all of the above consent and I fully understand what I am signing and hereby request and consent to treatment using hormone supplementation therapy.

Signature

Clear Signature

HIPAA Information and Consent Form

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.

2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.

3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.

4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.

5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.

6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.

7. We agree to provide patients with access to their records in accordance with state and federal laws.

8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.

9. You have the right to request restrictions in the use of your protected health information and to request changes in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any

subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

Signature

Clear Signature

Blood Work *

Price: $225.00

Credit Card *

Card

Name on Card

Total

$0.00

BlooD Work

Optimized Health Solutions

revv application

Consent for Hormone Replacement Therapy

HIPAA Information and Consent Form

We have adopted the following policies:

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