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Forms

Forms

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

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    Our Doctor

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