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"YOUR PHARMACY NAME HERE"

***NOTE TO PROSPECTIVE MARKETING PHARMACY - THIS FOLLOW-UP FORM, WHEN COMPLETED WILL BE DIRECTED TO AN E-MAIL OF YOUR CHOICE.  THIS ALLOWS PATIENTS TO COMMUNICATE ANY ISSUES THEY MAY BE EXPERIENCING WITH THERAPY AND ALLOWS THE PHARMACIST TO CHECK PATIENT COMPLIANCE.

Patient Follow-Up Request Form

As a Bio-Identical Hormone Replacement Patient you can fill out the form below to request a FREE follow up appointment with the compounding pharmacist to discuss any current or new symptoms that concern you.  The form and the questions asked are designed to provide the pharmacist with the important information needed prior to the consultation.  Answering all required questions can help identify possible medication administration errors.  Feel free to also list any questions that you may have regarding your therapy.  Make sure to click on the "Submit" button when finished.

This Is For "Your Name" Pharmacy Patients Only.

Any Fields Marked With An Asterisk "*" Are Required.

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First Name *   Last Name *

Day Phone *    Night Phone

E-Mail Address *

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Prescription #1

Rx # (Located above your name on the prescription label) *

Drug Name (Please include name as seen on label)  *

Strength of Medication (Please include units, ex. 100mg/ml) *

How Much Of This Medication Do You Use A Day?  Please do not copy the words on the label.  Use your own words in describing the quantity you use.  If you are using a cream let us know the know how you determine the amount you need to use.  This is important in determining if the medication is being used correctly.

*

How Many Times A Day Do You Take This Medication? *

What Is Your Consistency In Using This Medication? *

Are You Having Any Particular Problems Using This Medication?  (List Below)

If you have more prescriptions please list them below, if not scroll down to the SYMPTOMS section of the form.

Prescription #2

Rx # (Located above your name on the prescription label) 

Drug Name (Please include name as seen on label) 

Strength of Medication (Please include units, ex. 100mg/ml)

How Much Of This Medication Do You Use A Day?  Please do not copy the words on the label.  Use your own words in describing the quantity you use.  If you are using a cream let us know the know how you determine the amount you need to use.  This is important in determining if the medication is being used correctly.

How Many Times A Day Do You Take This Medication?

What Is Your Consistency In Using This Medication?

Are You Having Any Particular Problems Using This Medication?  (List Below)

Prescription #3

Rx # (Located above your name on the prescription label) 

Drug Name (Please include name as seen on label) 

Strength of Medication (Please include units, ex. 100mg/ml)

How Much Of This Medication Do You Use A Day?  Please do not copy the words on the label.  Use your own words in describing the quantity you use.  If you are using a cream let us know the know how you determine the amount you need to use.  This is important in determining if the medication is being used correctly.

How Many Times A Day Do You Take This Medication?

What Is Your Consistency In Using This Medication?

Are You Having Any Particular Problems Using This Medication?  (List Below)

Prescription #4

Rx # (Located above your name on the prescription label) 

Drug Name (Please include name as seen on label) 

Strength of Medication (Please include units, ex. 100mg/ml)

How Much Of This Medication Do You Use A Day?  Please do not copy the words on the label.  Use your own words in describing the quantity you use.  If you are using a cream let us know the know how you determine the amount you need to use.  This is important in determining if the medication is being used correctly.

How Many Times A Day Do You Take This Medication?

What Is Your Consistency In Using This Medication?

Are You Having Any Particular Problems Using This Medication?  (List Below)

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SYMPTOMS - If You Do Not Have Any Symptoms Please Scroll Down To The Last Section Of The Evaluation.

Symptom #1  

How Often Does This Symptom Occur And At What Time(s) Of The Day?

 

Please List Any Additional Comments Regarding This Symptom Below.

Symptom #2  

How Often Does This Symptom Occur And At What Time(s) Of The Day?

 

Please List Any Additional Comments Regarding This Symptom Below.

Symptom #3  

How Often Does This Symptom Occur And At What Time(s) Of The Day?

 

Please List Any Additional Comments Regarding This Symptom Below.

Symptom #4  

How Often Does This Symptom Occur And At What Time(s) Of The Day?

 

Please List Any Additional Comments Regarding This Symptom Below.

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ADDITIONAL INFORMATION

Have you experienced any type of stress (physical, emotional, physiological) recently?  If so, please describe below.

Have You Experienced Any Changes In Diet or Weight Recently?  If so describe below.

Have You Started Any Other Medications, Vitamins, Or Over The Counter Supplements Recently?  If so, list them below with the approximate time they were started.

Do You Have Any Additional Questions Or Comments For The Pharmacist?

Please Make Sure To Press The Submit Button To Ensure Delivery.

 

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NOTE: California Residents - Business and Professions Code 1246.5 Requires That Any Test that has not been approved by the Federal Food and Drug Administration for sale to the public without a prescription as an Over-The-Counter Test kit must be ordered by a Licensed physician acting on a patient's behalf.  All orders for test kits within the state of California

NOTE: New York State Residents New York State health law prohibits the testing of certain specimens collected in or mailed from New York, and prohibits the transmission of data from our laboratory to NY physicians or residents. Therefore, direct receipt of lab results for NY residents is not possible.

International Residents & Orders:  Extra shipping charges may be added for international orders.  Patients will be contacted by e-mail or telephone to approve charges.