New Patient Form

    Patient Authorization for Delivery of Medication(s)

    I, , 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. Delivery varies based on location.

    No Guarantee of Services

    We do not guarantee that any services or medications that will be recommended to you will guarantee results. Results vary based on the individual.

    Hormone Response and metabolism differs greatly from each individual and attaining and sustaining specific levels are impacted by many factors including age, weight, mental/physical stress, diet, exercise medications/supplements you may or may not be taking. Labs will be used throughout treatment for evaluation and monitoring each individual.

    Once signed up for services, provider examination and at the provider’s discretion only, you will be provided medications and/or services during your program at Las Vegas Health and Hormone.

    Patient Signature: Today's Date:

    Informed Consent for Hormone Replacement Therapy (HRT)

    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 provider or Las Vegas Health and Hormone. When hormone levels are brought back to “optimal”, there is much evidence that your overall health benefits. Tangible benefits include increased energy, enhanced mental clarity and an increase in sex drive. The natural anti-inflammatory effects of testosterone can also lessen joint pain and improve bone health. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment. The current medical thinking is always changing, so it is important to discuss HRT with your provider 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 sex hormones with my provider 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 (while on treatment, some may have the need for therapeutic phlebotomy), stroke, heart attack, acne, breast tenderness, hair loss or gain or deepening of the voice. 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 provider. I understand that my provider 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 provider prescribe them for me.

    Full Name: Date of Birth:
    Patient Signature:
    Today's Date:


    General Information

    Patient Full Name:
    Street Address:
    City, State, Zip:
    Phone Number:
    Preferred Method of Communication:
    Date of Birth:
    Driver's License or Government Issued ID:
    Upload Driver's License or Government Issued ID:
    What program(s) and/or medication(s) have you tried and did they work?

    Do you plan to have children in the future?

    Family Physician and/or Primary Health Care Provider:


    May I send a copy of your consultation to your physician or primary health care provider and consult with them as necessary?

    Patient Signature:
    Today's Date:

    How did you hear about us?
    If personal reference: Name:
    If Other, please specify:

    Emergency Contact:
    Name: Phone Number:
    Relationship to Patient:

    What is (are) your purpose(s) for participating in this HRT program?

    - Have you ever competed or are you currently training for a competition? If yes, when?
    If yes, how much?


    Present Medical History

    Check those questions to which you answer "yes" (leave all others blank)

    If you have had heart trouble, when:


    Do you now or have you recently experienced any of the following?


    Men ONLY
    Do you now have or have you recently experienced any of the following?

    Are you aware Hormone Replacement can lower sperm count?
    Have you ever been told NOT to do HRT?

    Women ONLY
    Do you now have or have you recently experienced any of the following?

    Date of Last Cycle:
    If no longer having a cycle, why:
    If yes to Hysterectomy;
    Date of last pelvic exam and/or PAP smear:
    Type of Birth Control (if applicable):
    Have you ever been told NOT to do HRT?
    Have you ever been told NOT to use Hormonal Birth Control?
    Have you ever been told NOT to use Estradiol or Progesterone?
    If yes, why?

    Are you currently on any type of hormone replacement therapy?:
    If yes, please list:
    What Kind?: Date of Last Treatment: Dose:

    Answer the Following:
    List any prescription medications you are now taking and/or have taken in the last 6 months: (Include blood pressure meds, anti-depressants and pain meds)

    If you are currently on anti-depressant medications, some narcotic analgesics or some blood pressure medications, I understand that the Las Vegas Health and Hormone is in no way advising me to stop my medication(s), or to wean myself off any medication(s), without the direction of my prescribing provider/physician. I have been advised that this may hinder the progress of my treatment rather than seeing immediate improvement.


    List any self-prescribed medications, dietary supplements or vitamins you are now taking:

    List any known drug allergies:

    Date of last complete physical examination:

    Date of last chest x-ray:

    Date of last electrocardiogram (EKG or ECG):

    Date of last dental checkup:

    List any medical or diagnostic test you have had in the past two years:

    List hospitalizations, including date(s) and reason(s) for hospitalization:

    Past Medical History

    Check those questions to which you answer "yes" (leave all others blank)

    Please explain clotting disorder information:
    Please explain thyroid issue information:
    Please explain autoimmune condition(s):
    If yes to stroke, when:

    Cancer Type:
    Date of Remission:
    Type of treatment:

    Please explain Cardiovascular conditions:

    Have you ever been told not to take HRT?

    If yes to any of the above, please explain when and treatment:

    Family Medical History

    Current Age:

    My father's general health is:

    Reason for poor health:
    Age at Death:
    Cause of Death:

    Current Age:

    My mother's general health is:

    Reason for poor health:
    Age at Death:
    Cause of Death:



    Card Type:

    Credit Card Number:
    Expiration Date:
    CVC Security Code:
    Billing Address:
    Zip Code:
    Name on Card:
    Authorized Signature:

    Would you like to move forward with ordering labs:
    *Our basic panel is $150, a discounted price through LabCorp. The Basic Panel consists of CBC, CMP, Lipid Panel, TSH, PSA/HCG, Estradiol and Testosterone. If you are planning on taking GH, you need an additional IGF-1 which is an additional $75. We can send you a lab order. For a fast, easy way to see your labs or make a lab appointment, create a LabCorp account through the link below:

    By signing this form, you give Las Vegas Health and Hormone permission to keep the above credit card on file and charge it for future orders. the card on file can be charged prior to your next transaction. You are authorizing Las Vegas Health and Hormone to charge and sign your card for future transactions using AUTHORIZE.NET.

    *Las Vegas Health and Hormone reserves the right to have a NO RETURN and NO REFUND policy.*

    **All orders will be processed once the payment clears. Please allow 10-14 business days for all orders to be processed.**

    ***ALL order, MED's and/or lab charges are final, no refunds. You must let us know within 24 hours of receiving the order if anything is missing.***

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    Clinic Hours
    By Appointment Only

    Monday – Friday:  8:30am – 4:30pm
    Saturday:              CLOSED
    Sunday:                CLOSED

    The Services provided have not been evaluated by the Food and Drug Administration. These products are not intended to diagnose, treat, cure or prevent any disease. The material on this website is provided for the informational purposes only and is not medical advice. Always consult your physician before beginning any treatment program.