BOOK A HORMONE CONSULT BOOK A HORMONE CONSULT Step 1 of 5 20% Patient Type(Required) I am a new patient I am a returning patient Full Name(Required) First Last Your Email Address(Required) Your Phone(Required)Postal Address for delivery of products(Required) Street Address Suburb State Postcode How did you hear about us? Word of mouth Google search Instagram/Facebook Social media group If a phone call is required, what is the best time to call?(Required) 8am-10am 10am-12pm 12pm-3pm 3pm-5pm Tell Us More About You:Date Of Birth(Required) DD slash MM slash YYYY Occupation(Required)Height(Required)Weight(Required)Are You Pregnant/Breastfeeding/Trying To Conceive ?(Required) Yes No (Please note: If you become pregnant, please stop treatment and let our team know.)Please Specify Pregnant Breastfeeding Trying to conceive Undergoing fertility treatments Do you experience menstruation? Yes No Please advise the reason why. Tell Us A Little Bit About Your Medical History.Do you have a family history of cancer?(Required) Yes - paternal side Yes - maternal side No Please specify the type/s of cancer.Have you ever experienced or currently have any of the following medical conditions.(Tick all that apply) Abnormal vaginal bleeding Blood clots Diabetes Endometriosis Fibrocystic Breasts Heart disease High blood pressure Impaired liver function Osteoporosis Ovarian cysts Polycystic ovary syndrome Stroke Thrombophlebitis Uterine fibroids What medications or supplements are you regularly taking, if any?Have you ever had an allergic reaction to a medication? If so, please specify and describe reaction: Tell Us About Your Concerns.What symptoms are you currently experiencing?(Tick all that apply) Headaches or migraines Sudden or erratic changes in mood Unexplained loss of energy Brain fog or mental fog Depression, anxiety or other mental distress Difficulty sleeping or insomnia Nocturnal Hyperhidrosis (night sweats) Dry hair and/or skin Bloating or unexpected weight gain Incontinence Frequent urinary tract infections Hot flushes Vaginal dryness Painful or swollen breasts Premenstrual Syndrome (PMS) Low Libido or inability to reach orgasm Dyspareunia or pain during sexual intercourse How long have you been experiencing these symptoms? A few months 1-2 years > 2 years Can you think of any tiggers that may have contributed to these symptons? Tell Us About Your Goals.What improvements would you like to see?Are there any hormones or ingredients you would like to try?Would you also be interested in topical estrogen cream for your face?(Required)During the perimenopausal years, women can lose up tp 30% of collagen and elastin, leading to a noticeable decline in skin firmness and elasticity. Yes No CAPTCHAConsent(Required) I agree to the privacy policy.I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of advice or treatment. I consent to My Skin Pharmacy using the information to provide the best possible outcome and I confirm that I have read and fully understand this consent form. In accordance with the privacy act (1988) all information collected is treated as "sensitive information". To protect your privacy, My Skin Pharmacy operates in accordance with the act. Australian Federal Privacy Laws require the pharmacy to receive your consent to collect your personal medical information.Your medical information will be used exclusively for the purpose of providing health care and treatment.Hormone Consult Price: Total Credit Card American ExpressMasterCardVisaSupported Credit Cards: American Express, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Security Code Cardholder Name
