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Compounding for Healthcare Providers Compounding for Patients Specialty Compounding US compounding Contant Contact

Follow-Up with Our Staff

This form is for current patients only. Please let our staff know how you're doing, and we will contact you within 2 business days. Hormone balance is a journey, and we're here to help!

Name:
Email:
Address:
City:
State:
Zip Code:
Phone:
Summary of Symptoms:
Current Hormone Therapy Dosing or Prescription Number:
Please rate your symptom severity by making the appropriate selection below.

Weight Gain
Hot Flashes
Anxiety
Depression
Headaches
Irritability
Breast Tenderness
Acne
Fluid Retention
Fatigue - Morning
Fatigue - Daytime/Afternoon
Insomnia (Rate your sleep quality)
Night Sweats