Nationwide Synergy will not prescribe hormone replacement therapy for purposes of performance enhancement. Therapy will be provided only to those whose medical history, along with physical exam and lab work, show a clinical need for treatment. So, please be honest and thorough when answering each question on the following form. The symptoms you indicate are important in determining which therapy is right for you. Your information is completely confidential, and protected by Federal HIPAA regulations.
INSTRUCTIONS
YOU MUST SUBMIT THE FORM BEFORE YOU PRINT IT!
Answer all of the questions on the form as fully and accurately as possible.
When finished, press the "Submit" button at the bottom of the form.
The form will re-appear with your answers filled-in. Now you can print the completed form, sign it, and fax it to (561) 354-2744.
