Women's HRT Intake | Lavena Health

Step 1 of 6

Patient Information

Please complete all fields accurately. This information is used to coordinate your hormone replacement therapy care.

Personal Details

First Name *

Last Name *

Date of Birth *

State *

Race / Ethnicity (optional)

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 6 of 6

Informed Consent & Signature

Please read carefully. Your electronic signature is legally binding under Florida Statute §668.50.

Consent for Women's HRT

Nature of Treatment

I am consenting to receive hormone replacement therapy (HRT) prescribed by a licensed Florida physician through Lavena Health. Treatment may include estrogen, progesterone, testosterone, or combinations thereof, delivered via patch, cream, gel, oral, pellet, or injection as determined by my provider based on my clinical profile and preferences.

Potential Benefits

Relief from hot flashes, night sweats, and vasomotor symptoms
Improved sleep, mood, and cognitive function
Improved libido and sexual function
Bone density protection and reduced fracture risk
Improved energy, skin health, and quality of life
Potential cardiovascular protective effects when started in the first 10 years of menopause (Window of Opportunity)

Risks & Side Effects

Breast tenderness, bloating, or spotting — especially during initiation; typically resolves
Increased risk of blood clots (VTE) — lower risk with transdermal vs oral estrogen
Breast cancer risk — complex and individualized; bioidentical progesterone may carry lower risk than synthetic progestins; discuss your personal risk profile with your provider
Endometrial cancer — estrogen-only therapy increases risk; progestogen must be added if uterus is intact
Stroke risk — primarily associated with oral estrogen; transdermal route largely mitigates this risk
Mood changes — some patients experience mood fluctuations during the first 1–3 months
Androgenic side effects with testosterone — acne, hair changes; managed with dose adjustment

Breast Cancer Disclosure

I understand that the relationship between HRT and breast cancer risk is complex and individualized. My provider will discuss my specific risk profile, including personal and family history, before prescribing. I confirm I have fully disclosed my complete personal and family history of breast cancer in this form.

Monitoring Requirements

I agree to maintain current with recommended cancer screening (mammogram, Pap smear) and to complete any baseline and follow-up laboratory testing as directed by my provider. I will report any new symptoms — particularly unscheduled bleeding, breast changes, or leg swelling — to my provider promptly.

Direct-Pay & Truthfulness

I certify all information in this intake is truthful and complete. I understand Lavena Health is a cash-pay clinic and no insurance is billed. I may withdraw consent at any time.

Identity Verification

Why we ask: Florida law and federal telehealth regulations require that prescribing physicians verify patient identity before issuing prescriptions. Your attestation below satisfies this requirement for your initial intake. A government-issued photo ID may be requested at or before your first consultation.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the risks and benefits of HRT as described above.

I have fully disclosed my complete personal and family history of breast cancer, blood clots, and cardiovascular disease.

I agree to maintain current cancer screening (mammogram, Pap) and complete any baseline and follow-up labs as directed by my provider. I will report any new or concerning symptoms promptly.

I confirm I am 18 years of age or older, am the patient named in this form, and voluntarily consent to HRT through Lavena Health. All information provided is truthful and complete.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your full legal name above and clicking Submit, you provide a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Patient Information

Symptom Assessment

Gynecological History

Medical History

Medications & Lab Values

Informed Consent & Signature