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Step 1 of 5 ~3 minutes

Let's start with the basics.

Tell us a little about yourself so we can set up your chart correctly.

Please enter your first name.
Please enter your last name.

We'll use this in all communications.

Please enter your date of birth.

Used for lab reference ranges only.

Please select a legal sex for lab ordering.
Please enter a valid email address.
Please enter a phone number where we can reach you.

What brings you in?

Select everything that resonates. We use this to personalize your intake before you even walk in the door.

I'm here about… (select all that apply)
Please share a little about what's been going on — even a few words helps us prepare.

Medical history.

This helps us order the right labs and avoid contraindications. Approximate answers are fine — we'll do a full review together.

Include vitamins, supplements, OTC medications.

A few quick questions

These help us tailor the right labs and avoid anything contraindicated. Approximate answers are fine.

Which hormones? (check all that apply)

Known medical conditions

Check anything that applies. Categories you don't relate to, just skip.

Cardiovascular
Cancer history
Gynecological Urological & prostate Gynecological / urological
Endocrine & metabolic
Neurological
Autoimmune
Organ-specific conditions

Have you used hormone therapy before?

Leave blank if you haven't had recent labs — we'll order them.

Lifestyle & symptom picture.

Hormone health doesn't exist in a vacuum. These details help us see the full picture — no judgment here.

5
1 — Very low 10 — Extremely high

Symptoms & concerns

Check everything you've been experiencing. This is a comprehensive list — most people only check a handful.

Symptoms scale

For each symptom, rate how often you experience it right now. This gives Nathalie a baseline to measure your progress against.

Physical exhaustionFatigue, lack of energy, stamina, or motivation
Sleep problemsDifficulty falling asleep or staying asleep through the night
IrritabilityMood swings, feeling aggressive, angering easily
AnxietyFeeling overwhelmed, panicky, or nervous
Decline in drive or interestLoss of “zest for life,” feeling down or sad
Joint and muscular symptomsPoor recovery, inability to build muscle, joint pain, weakness
Memory difficultiesConcentration, finding the right word, retaining information
Sexual desire or performanceReduced or diminished
Erectile changesWeaker erections, loss of morning erections
EjaculationsInfrequent or absent
SweatingNight sweats or increased episodes of sweating
Hair lossRapid or thinning
Feeling coldCold hands or feet, feeling cold all the time
Headaches or migrainesIncrease in frequency or intensity
WeightDifficulty losing weight despite diet and exercise
Bladder problemsDifficulty urinating, increased need to urinate

Almost there — consent & preferences.

Plain-language, no legalese. Read, check, and we're done.

A note on privacy: This form transmits your information to our practice over an encrypted connection. It is not stored in a certified HIPAA-compliant system and should not be used to transmit highly sensitive medical details beyond what is asked. A signed Business Associate Agreement (BAA) with our email and data providers is required for full HIPAA compliance — we are working toward that. Your information will not be shared with third parties.

Informed Consent

I understand that by submitting this form I am beginning a patient intake process with Nathalie Hormone Health. I acknowledge that hormone therapy involves potential risks and benefits that will be discussed with my provider before any treatment begins. I consent to the collection and internal use of the health information I provide here for the purpose of preparing for my first visit. I understand that this form does not establish a patient-provider relationship and does not constitute medical advice.

HIPAA Privacy Notice

You have rights regarding your health information under the Health Insurance Portability and Accountability Act (HIPAA). We collect only the information necessary to provide your care. We do not sell your data. You may request access to, correction of, or deletion of your information at any time by contacting us at hello@nathaliehormonehealth.com.

Both consent boxes must be checked to proceed.

We are a self-pay friendly practice. Insurance is accepted for labs at Quest / LabCorp. See Pricing for details.

We'll let you know in advance what's covered vs. out-of-pocket.

Intake received

We'll be in touch within 1 business day.

Your intake has been sent to Nathalie's team. Here's what happens next.

Confirmation ID: NHH-------

What to expect

  1. You'll receive a confirmation email at the address you provided — check your spam folder just in case.
  2. A member of our team will review your intake and reach out to schedule your first appointment within one business day.
  3. Before your visit, take a look at our Prep for Your First Visit guide — it covers what to bring, what to expect, and how to get the most out of your 60–75 minute appointment.
  4. Labs may be ordered in advance depending on your intake responses, so we can review results together on the day of your visit.
Prep for your first visit Back to home