Cuda Health

Intake Form

Have you been a client of an HRT clinic in the last 12 months? If so, who? *

Please describe concerns you have, goals for treatment, and anything else you would like us to know. *

How did you hear about us? *

Patient Information

First Name *

Last Name *

Date of birth *

Address

Street Address *

City *

State *

Country *

Postal Code *

Email *

Phone *

Biological Sex *

Any other medical or diagnostic tests you have had in the last two years? *

Are you currently on any type of hormone replacement therapy? *

Any prescription medications you are now taking? *

Any known drug allergies and reactions? *

Any self-prescribed medications, dietary supplements, or vitamins you are now taking? *

Are you interested in medications to help with joint/ligament pain/recovery?

Yes

Not at this time

I am unaware of the options

Telemedicine Consent & Acknowledgment

By signing below, I consent to receive healthcare services through telemedicine from Cuda Health and its affiliated healthcare practitioners. I understand that telemedicine may include consultation, evaluation, treatment recommendations, and prescribing when deemed medically appropriate by the treating practitioner.

I understand the potential benefits and limitations of telemedicine, including that an in-person examination may sometimes be recommended or required. I understand that no specific treatment, medication, prescription, or medical outcome is guaranteed.

I authorize Cuda Health and its affiliated practitioners to contact me by phone, text message, and/or email regarding my care, appointments, prescriptions, orders, and other healthcare-related communications.

I confirm that the information I have provided in this intake form is accurate and complete to the best of my knowledge. By signing below, I acknowledge that I have read, understand, and voluntarily consent to the above.

Signature

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