Medical Intake Form

The form below is to be completed by the patient, or on the patient’s behalf, including detailed responses to all questions that apply to the applicant’s medical history and for which treatment is being considered. These details will assist the medical team in determining if the patient is a candidate for Hormone Management Therapy.

"*" indicates required fields

Patient Contact Information

Full Name*

Full Name *

First Name*

Mid. Init.

Last Name*

Email Address *

Email Address*

Date of Birth *

Date of Birth*

Age *

Age*

Physical Characteristics *

Height - Feet*

Height - Inches*

Weight*

Primary Phone *

Primary Phone*

Alternate Phone

Address*

Street Address City State/Province Postal Code Country

Emergency Contact

Emergency Contact*

Emergency Contact Phone

Emergency Contact Phone*

Emergency Contact Relationship

Emergency Contact Relationship*

Primary reason for exploring hormone management therapy?*

Please describe your symptoms:*

Patient Application Statement and Agreement

Stemedix™ offers patients the opportunity to connect with licensed medical doctors who use Hormone Management Therapy as part of their clinical practice. Hormone Management Therapy is currently not the standard of care and the following important disclosures are made:

Treatments described are not approved by the United States FDA and are not considered to be any standard of care for any condition or disease.
There could be significant and unknown risks associated with Hormone Management Therapy.
Treatments by licensed providers will only be performed after the patient understands and agrees to informed consent(s).

By checking the box below, you agree that you have read and understand all the statements above.

Hidden

Patient Agreement

I agree*

I Agree*

Note: Please verify that all required fields are filled in correctly before submitting the form. Once clicking the submit button, you will be taken to a "Thank You" confirmation page. If you are not redirected to the "Thank You" page, scroll up and verify you have filled in all the fields correctly. The form is not submitted until you reach the "thank you" confirmation page. If you are having issues filling out the form, please contact us at 800-531-0831 for assistance.

Medical Intake Form

Patient Contact Information

Men's Health

Medical Information

Patient Application Statement and Agreement

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Medical Intake Form

Patient Contact Information

Men's Health

Medical Information

Patient Application Statement and Agreement

DISCLAIMER

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