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ProgestRXreq

Progest RX Request

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Please fax my doctor a note requesting a prescription for Progesterone for me.

Name *

Address *

Birthdate & Age *

Day time phone # *

Home phone #

cell phone #

Drug Allergies

What medications have you used in the past or are currently using to treat your condition?

What other medications do you take?

How tall are you?

About how much do you weigh?

Have you had a hysterectomy

YES NO

What was the reason for your hystectomy?

Are you still having a monthly period

Please check any of the following problems that you are hoping will improve with the progesterone:

Endometriosis

Fibrocystic Breast Disease

Heavy Bleeding

PMS

Peri-menopause

Menopause

Uterine Fibroids

Please check the severity of these problems

Mild Moderate Severe

Are you having trouble sleeping?

YES NO

What bothers you more?

Falling Asleep Staying Asleep Both

Name of doctor you want us to fax this request to:

Doctor's Phone # or where they practice

We will take this information and fax a note to your doctor requesting a prescription for Progesterone for you. When we hear back from the doctor, we will contact you.

( * Required Field )

3349 Highway 31, Suite 102
Homewood, AL 35209
Office 205-870-3150
Fax 205-870-3160
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