This agreement between (patient) and Physician Monitored Program establishes guidelines and conditions required for the use of hormone replacement therapy (HRT) involving DEA "controlled" or” scheduled" medications. Hormone Replacement Therapy Board Certified Physician Prescribed HRT Program Solutions and (patient) agree that these guidelines and conditions are an essential factor in maintaining a successful patient/physician relationship.
Before submitting, please verify all the information is correct and print this form for your records. Patient agrees and consents to conduct business and transactions by electronic means, Electronic signature confirms authorization and agreement to the terms and conditions referenced above. This form is for pre-qualification only and a hand signed document is required for final approval by our physicians.
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