Influencer - Laura's Consultation & Intake Form

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Your Time Zone

Biological Gender

Date of Birth

Do you have an Insurance Provider?

Yes
No or Self Pay

Amazing Meds accepts insurance for labs and provider visits. If you are planning on using your insurance should you choose to move forward with treatment, please submit your information above. We Accept: Medicare, Medicaid, Anthem BCBS, AARP, Coventry, HealthSmart, TriWest, Tricare, UHC, and VA

Please describe the other symptoms you're experiencing:

Do you drink alcohol?

Yes
No

Number of drinks per week:

Are you or your partner currently trying to conceive?

Yes
No

Which birth control method are you currently using?

Are you currently taking any medications?

Yes
No

Have you ever had an allergic reaction to any medications?

Yes
No

Are you currently undergoing any form of hormone replacement therapy?

Yes
No

Do you have any food allergies?

Yes
No

Please list any over-the-counter medications, dietary supplements, or vitamins you are currently taking:

Confirmation & Consent

By clicking "I agree to all and confirm," you affirm that the information you have provided is accurate.

Additionally, you acknowledge that you have thoroughly reviewed and agreed to the Health Care Services Consent, Hormone Replacement Therapy Informed Consent, the Authorization and Consent to Participate in Telemedicine/Telehealth Consultation, the HIPAA Notice of Privacy Practices, and the Self Payment Agreements. You also agree to receive electronic communications from Amazing Meds, understanding that these messages may include personal information, will not be encrypted, and could be accessed by others with access to your email and/or SMS/MMS text message accounts.

Confirmation and Consent

I agree to all and confirm *

Your Next Steps To Better Health

1) Schedule Your Consultation

This 20-minute (or longer if you need it!) virtual session is designed to address your unique health concerns and guide you toward a customized hormone replacement therapy plan.

Our dedicated case manager will review your information and discuss your symptoms, medical history, and lifestyle factors with you to understand your specific needs.
Receive personalized recommendations on hormone replacement therapy, including potential benefits, treatment options, and next steps tailored to your health goals.
Enjoy the comfort and privacy of a virtual consultation from your home or office.
You will gain valuable insights into your hormone health and leave the consultation with a clear action plan, including suggestions for lab tests or provider visits if needed.

2) Review Your Personalized Treatment Plan

After your initial consultation and any required provider visits or labs, our medical team will create a customized HRT plan tailored to your specific needs and goals.

3) Begin Your Journey To Improved Hormone Health

Start experiencing the benefits of HRT as you embark on a path to feeling healthier and more balanced.

Why Choose Amazing Meds?

Our team, led by Dr. Jennifer Frangos, DO, specializes in hormone replacement therapy, providing empathetic and personalized care. Dr. Frangos' passion for telemedicine enhances patient access, making high-quality hormone replacement therapy more accessible than ever.

We're not just about treatments; we're about solutions that fit your life.
We know that "normal" isn't always what's best for you. We dig deeper to find what truly works.
Your health, your way. From the first consultation, you'll feel the difference of a care team that's on your side.

We know that quality care only works when it's a partnership, where every person feels seen, heard, and valued. With Amazing Meds, expect a level of care that's as unique as you are.

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