Hormone Form | Benton Integrative Medicine | Huntersville, Denver, Charlotte NC

First name

Phone

Last name

Date Of Birth

Age

Zipcode

How did you hear about us?

Please briefly list the top 2-3 symptoms you are hoping to address:

Please list other health concerns that you believe are affecting your wellbeing:

Do you have a monthly cycle? If yes, has your monthly cycle changed recently and how has it changed?

Please list any birth control you have ever been on or are currently on and the (approximate) dates that you’ve been on this birth control.

Are you interested in Hormone Replacement Therapy (if appropriate)?

Are you currently taking or have you ever taken Hormone Replacement Therapy? If yes, please list the HRT you are currently on or have been on and the dates.

Do you have a history of breast, ovarian, cervical or endometrial cancer and what treatments did you undergo? (i.e. mastectomy, hysterectomy etc.)

What are your goals and what are you hoping to achieve from this appointment?

Insurance Name

Group Number

Member Number

Anything else you would like to share?

Hormone Consultation Intake Form

At Benton Integrative Medicine, we are committed to doing all we can to support you and the following questions will help us learn more about the best fit for your needs. Once completed and reviewed by our hormone specialist, you will be contacted to schedule a consult along with provided with any recommended testing that will best support your individual goals and circumstances. We look forward to working with you on your journey to greater vitality!

Please fill out the form below to get started. We will contact you to set up an appointment to get started.

Benton Integrative Medicine

a holistic concierge medical center

(704) 775-6029

Specials & Events

Direct Primary Care

Hormone Consultation Intake Form

Huntersville Location

Hours

Denver Location

Hours

T: (704) 775-6029 | F: (704) 413-3198 | EMAIL US

Direct Primary Care

Sexual Health

GAINSWave For Her

Functional Medicine, Hormones & Wellness

Health Coaching

Supplements

Blog

Health Tips Videos

Self Care

a holistic concierge medical center

Hormone Consultation Intake Form

Huntersville Location

Hours

Denver Location

Hours

T: (704) 775-6029​​ | F: (704) 413-3198 | EMAIL US

T: (704) 775-6029 | F: (704) 413-3198 | EMAIL US