Ryze Medical Form Name(Required) First Middle Last Email(Required) Phone(Required)Referral CodeBirthday(Required) MM slash DD slash YYYY Ethnicity(Required)American IndianAlaskan NativesAsianBlack African AmericanHispanic or LatinoWhiteNative Hawaiian or Pacific IslanderOtherPrefer Not To SaySex(Required)MaleFemaleOtherAddress(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License Number(Required)We are going to need copy of your driver's license prior to ordering medication. Please write down your driver's license number and upload a copy of the license.Upload Driver's License(Required) Drop files here or Select files Max. file size: 5 MB, Max. files: 1. Do you have recent labs including sex hormones (done within the last 6 months)? Yes No In as much detail as possible, please explain your purpose for reaching out to Ryze HRT (please note that lack of detail may result in delayed enrollment)(Required)Medical History(Required)MedicationsSupplementsAre you allergic to any medications ?Autoimmune & Stealth InfectionHave you ever been bit by a tick?(Required)Do you have any history of camping, trail hiking, horseback riding, or wildlife activities or water activity?(Required)Do you have any awareness of living or working in an environment with mold?(Required)Have you been diagnosed with any of the following autoimmune conditions? Hashimotos rheumatoid arthritis graves' disease diabetes addison's disease celiac, crohn's ulcerative colitis psoriasis / psoriatic arthritis alopecia lupus multiple sclerosis fibromyalgia Have you received any lab results showing elevated antibodies? If so, which ones?(Required)REVIEW OF SYMPTOMSIf you have any of the symptoms below, please check the appropriate boxes, otherwise leave them blank !General Change in Appetite Change in weight Fatigue Difficulty Sleeping Anxiety Depression Hormones Poor Motivation Low Sex Drive Poor sexual function Brain fog Irritability Mood Instability Irregular, Heavy or No Menstrual Periods Skin Sores That Don't Heal Dry Skin Hair changes Allergies Seasonal Allergies Hives Food Allergies Eyes/ Nose/ Ears/ Mouth/ Throat Loss of Vision Difficulty Swallowing Lump in the Neck Voice Changes Lungs Shortness of Breath Persistent Cough Wheezing Heart Chest Pain Heart Racing Swollen Ankles Gastrointestinal Heartburn Frequent Nausea Abdominal Pain Frequent Diarrhea/ Constipation Musculoskeletal Muscle/Joint Soreness Generalized Weakness Difficulty Recovering Have you ever been on any form of HRT ? How long ago ?INFORMED CONSENT FOR RYZE HRT’S SERVICES:I understand that Ryze HRT’s Consultants/Specialists do not replace my primary care provider. I understand and accept that the guidance and treatment recommendations involve some risk. These risks include but are not limited to breast or endometrial cancer, blood clotting, stroke, heart attack, allergic reactions, and adverse side effects. I am aware that there are risks if I take any medication, including HRT. I have discussed these risks and the reasons for taking them, with my provider and I want to proceed with therapy. I accept all risks and do not hold Ryze HRT LLC or its agents and affiliates liable for the risks associated with taking HRT. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT, and I agree to follow the ultimate advice and recommendations of my provider. I understand that Hormone therapy is very individualized and that there are no guarantees that these measures will be effective, and I am participating in this therapy with that understanding. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them and guide me through a therapy for me. I am aware that in the practice of medicine, unexpected complications and risks that were not discussed with me may occur. I understand the proposed treatments might reveal unforeseen conditions. These conditions might result in the processed treatments changing. I am voluntarily participating in treatment. I assume all known and unknown risks of my participation in these treatments and procedures. I further agree to indemnify, defend, and hold the and its affiliates harmless against all claims and suits of action against liability, compensation, damages, or otherwise brought to me. I further understand the contents of this medical liability waiver form. I received the opportunity to ask questions and receive satisfactory answers. I understand that all payments for diagnostic testing, treatments, and/or other services by Ryze HRT are final and non-refundable. I also understand that once my treatment arrives, it cannot be returned or refunded, and if not used, must be discarded. I agree to the HRT policy Yes Name First Middle Last I agree to the HIPAA FORMS Service Privacy Statement ! Yes Please Sign Here(Required)CAPTCHA
