Bio-Identical Hormone Follow-Up Testing Preparation Form

Your next bio-identical hormone (BHRT) follow up is due shortly. As you know, the doctor will want to review test results with you at that time. In order for the doctor to order the most appropriate tests for you, we require the following eForm to be completed:

I am taking my prescription exactly as written
My prescription dosage or frequency has changed. I am now taking:
I do not have any other prescriptions
I take other prescriptions that have been prescribed elsewhere:
No, I am feeling well
Yes:

* denotes a required field

Note: This form must be returned within two weeks of being notified. Please contact us should you need more time. If we do not receive the form or notification from you within two weeks, we will assume you are no longer interested in the program.


Thank you for taking the time to complete this form!


Disclaimer: Submitting information through this form is voluntary and no guarantee can be made to the security of this form and website. If you prefer to provide the information by phone, please call The De Pieri Clinic at 250-448-7408. All information provided is considered to be confidential, privileged, and only for our internal use. It will not be published or redistributed.

The De Pieri Clinic

Expertise and Caring in Aesthetic & Anti-Aging Medicine
106 – 1353 Ellis Street - Kelowna, BC - 250-448-7408

Botox Cosmetic, Juvederm Ultra, Latissee
Dr. Andrew De Pieri
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