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Natural Hormone Replacement Therapy
Dr. Trey Waters PharmD, RPh, FAAFM
Dr. Shelley Laurich PharmD, RPh, FFSF
Alisa Sorenson RN, BSN

Use this form to request a consultation from one of our pharmacy staff to discuss you health or wellness needs.  Once we have received your inquiry we will contact you using the information provided to schedule your consultation. 

We look forward to assisting you,

Contact Info

Full Name: *
Address: *
City: *
State: *
Zip: *
Best Phone Number: *
Email: *
Personal History

Physicians name: *
Physician's phone: *
DOB: *
Do you have prescriptions insurance: *
yes
no
if yes, name of insurance:
occupation:
employer:
have you had gastric bypass?:
yes
no
have you had a hysterectomy?:
yes
no
when?:
reason for hysterectomy:
what was removed?:
ovaries
left ovary
uterus
all
are you still having periods?:
yes
no
date of last period:
are your periods regular?:
have you gone more than 4 months without a period?:
yes
no
what was the date of your last mammogram?:
date of last pap smear:
list any female type of cancers or problems that you currently have or have had in the past? (ex. Fibrocystic disease, breast cancer, endometriosis):
do you smoke or use tobacco currently?:
yes
no
if so how many packs a day?:
have you had gallbladder or digestive problems?:
yes
no
blood clots or clotting problems?:
yes
no
have you had your cholesterol checked?:
yes
no
if so when?:
results:
have you ever had your bone density tested?:
yes
no
if so, results:
Family History
On your mother's side of the family, has there been any?
gynecological or female cancers?:
yes
no
if yes, type of cancer and realtion to you:
osteoporosis such as hip fractures, dowager hump, or easily broken bones?:
yes
no
heart attack:
yes
no
Medical History

list any allergies to medication you may have.:
list any chronic medical conditions you currently have: (such as diabetes, thyroid, arthritis, etc.):
list all hormones you have tried:
list all prescription medication you have currently take including your current hormones: *
list all vitamins/herbal supplements that you take daily or occasionally: *
What are your goals?: *
Verification Code -
please enter the letters
you see to the right: *