IS BHRT RIGHT FOR YOU? Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Gender * Please be advised that we do not offer hormone therapy for gender transition. For transgender hormone treatment, we recommend consulting with your healthcare provider. Male Female Date of Birth * MM DD YYYY Health Card Number * Currently offering treatment exclusively to SK and MB Health Card holders. Symptoms * Please select all that apply Fatigue or low energy levels Mood swings or irritability Reduced libido (sexual drive) Difficulty concentrating or memory problems Decreased muscle tone or strength Weight gain or inability to lose weight Sleep disturbances, such as insomnia or trouble staying asleep Joint pain or stiffness Hair thinning or hair loss Hot flashes or night sweats Changes in skin tone or elasticity Erectile dysfunction or difficulty maintaining an erection Health Conditions * Please select all that apply Personal history of prostate or breast cancer Severe untreated sleep apnea Personal history of heart failure, stroke, or heart attack Personal history of liver disease Personal history of blood clots (DVT/PE) Do you smoke or vape tobacco? * Yes No Thank you for completing our Bioidentical Hormone Replacement Therapy questionnaire. A member from our team will review your information and get back to you within 1-3 business days with next steps.
