No Need to Wait! Here’s a quick way to join the program right now! Please fill out our Confidential Qualifying Medical Questionnaire as well as the Consent for Treatment forms. PLEASE READ: Before we can effectively consult and provide you with the best level of medical service, it is required that you fill out our confidential qualifying medical history form and sign the necessary consent for treatment forms. This will take about 10 minutes of your time right now and will save you valuable time in the doctor’s office later. Please make sure you provide a valid phone number and email for a representative to be able to contact you to schedule labs, doctor appointments and process your payment. After successfully completing and submitting the confidential medical form, please call our medical center @ 561-693-0170 The following form establishes guidelines and conditions required for the use of Hormone Replacement Therapy (HRT) involving DEA “controlled” or “scheduled” medications. Patient(s) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship. Name* First Last Email* Enter Email Confirm Email Billing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*MobileSex*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Marital StatusSingleMarriedPreference of notificationsTextEmailBothHow did you hear about us?ReferralGoogleFacebookRadioMailingBillboardCommentsThis field is for validation purposes and should be left unchanged.