Let’s Get You Started

Please answer a few questions so the Vyta team can review your information and prepare for your care. Most questions take only one tap.

What is your first name? *

What is your last name? *

What is your date of birth? *

What is your sex? *

Male

Female

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What is the best mobile number to reach you? *

What is your email address? *

Address

Street Address *

Country *

State *

City *

Postal Code *

Are you currently taking any prescription medications? *

Yes

Please list your current prescription medications. *

Do you have any known allergies to medications? *

Yes

Not Sure

Please list your medication allergies and any reactions you have experienced. *

Is there anything in your medical history that the VYTA team should know about? *

Yes

Please briefly explain anything in your medical history we should know about. *

Are you currently experiencing any symptoms or health concerns we should know about? *

Yes

Please describe your current symptoms or health concerns. *

Have you ever been diagnosed with or experienced any of the following heart or circulation conditions? Select all that apply *

Have you ever been diagnosed with or experienced any of the following conditions? Select all that apply *

Have you ever been diagnosed with or experienced any of the following lung or respiratory conditions? Select all that apply. *

Please describe the other lung conditions *

Have you ever experienced any of the following injuries or musculoskeletal conditions? Select all that apply. *

Arthritis of the arms or legs

Back, leg, arm, or joint injuries

Broken bones

None of these

Have you ever been diagnosed with or experienced any of the following conditions? Check all that apply. *

Medication Delivery Authorization

I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used.

I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing.

I have read and agree to the medication delivery authorization above. *

I Agree

Clinic Policies

No Guarantee of Services

Vyta of Vegas does not guarantee that any services or medications will be provided until you have completed the preliminary sign-up process and physician examination. Any medications or services are provided at the physician’s discretion.

No Refund Policy

Vyta of Vegas maintains a no-return and no-refund policy.

I have read and acknowledge the clinic policies above. *

I acknowledge

Informed Consent for Hormone Replacement Therapy

Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use and the liability is on the patient not the doctor. When hormone levels are brought back to “normal” for your age there is much evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment. The medical frame of mind is always changing so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest information is.

Please read the following and sign: I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them and the risks associated with taking hormones including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different risks if I take any HRT medication. I have discussed these risks and the reasons for taking them, with my doctor. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT. I understand that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them for me.

I have read and understand the informed consent for hormone replacement therapy above. *

I understand and consent

Signature

Please sign below to confirm that the information you provided is accurate and that you agree to the acknowledgments and consent above.

Sign Here *

Clear

May Vyta send you appointment, treatment, and service-related text messages? *

Yes, I agree

Would you like to receive occasional offers and promotional text messages from Vyta?

Yes, keep me informed

No, thank you

Thank You

Your information has been submitted to the Vyta team. A team member will review it and contact you regarding the next step.