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Forms

Patient Forms

Here, you can find our patient forms sorted by relevant service. Click on the tab from the list below that corresponds to you to find the list of all the forms you need. 

General Forms

  • General Patient Information Form (Requires HIPAA)
  • Weight Loss New Patient Intake Form (Requires HIPAA)
  • HIPAA Authorization

    • BHRT Female Packet

  • Therapy Management Agreement
  • HIPAA Authorization
  • BHRT Patient Agreement for Treatment
  • Female Checklist
  • Female Hormone Balance Checklist
  • Female Patient Questionnaire and History
  • Female Patient Questionnaire
  • Female Pellet Consent Form

    • BHRT Male Packet

  • Therapy Managment Agreement
  • HIPAA Authorization
  • BHRT Patient Agreement for Treatment
  • Male Checklist
  • Male Patient Questionnaire and History
  • Male Patient Questionnaire and Medical History
  • Male Prostate Exam Waiver for Testosterone Pellet Therapy
  • Male Testosterone Pellet Insertion Consent Form

    • SA Prime Wellness