Now you can fill out your Confidential Medical History and Patient Symptom Survey online!  You can also request a Free BHRT consultation. Please fill out the forms to the best of your ability and if the question is not applicable, type none.  After submission, you will receive a Confirmation and an Email with a PDF of your filled out forms. Our professional staff will contact you within 2 business days.

Confidential Medical History Form and Patient Symptom Survey

Step 1 of 5 - Medical History Form

  • MM slash DD slash YYYY
  • Choose one.
  • Choose one.
  • Choose one.
  • If, no allergies, type none.