Required Documents for Treatment

About NSI

Hormone Optimization

Men: Andropause & Low-T

Testosterone Therapy

Women: Bio-identicals

Articles & Newsletters

Required Documents

Contact Us

		ONLINE Medical History Form You will need to print, sign, and fax to (561) 354-2744

		WOMEN; Please complete this step also!

Medication Management Agreement

Driver's License Copy
The law requires that you fax a copy of your Driver's License to (561) 354-2744

	Physical Exam Form
	Standard Physical Examination Form.

	Credit Card Purchase Confirmation 2011
	Confirms that the amount of a specified credit card purchase has been authorized by the patient.

	Credit Card Authorization
	An optional form that allows NSI to keep credit card information on file for future orders.

	List of Required Labs: Male
	A list of the laboratory tests NSI requires for all male patients.

	List of Required Labs: Female
	A list of the laboratory tests NSI requires for all female patients.

	Medical Records Release
	At NSI your records are confidential. A Medical Records Release is required if you are requesting that NSI send your records to another medical provider, or any third party.

NO TREATMENT WILL BE PROVIDED UNLESS A REVIEW OF YOUR MEDICAL HISTORY, PHYSICAL EXAMINATION, AND LAB TESTS REVEAL A NEED. COMPLETING THE REQUIRED MEDICAL HISTORY, LAB WORK AND PHYSICAL EXAMINATION DOES NOT AUTOMATICALLY QUALIFY YOU FOR THERAPY WITH NSI. ONLY OUR PHYSICIANS CAN DETERMINE IF YOU QUALIFY FOR TREATMENT.

The information provided on this website is not intended, nor should be construed as, medical advice.
Please consult with your own physician or healthcare provider before starting any therapy program.