Hormonotherapy Registration Form Step 1 of 3 33% Name(Required) First Name Last Name Date of Birth(Required) MM slash DD slash YYYY What is your sex at birth (biological)?(Required) I am a woman I am a man E-mail(Required) Enter Email Confirm Email Phone Number(Required)Address(Required) Number, street name Number, street name (If needed) Town AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province ZIP code Pharmacy name and Address(Required) How did you hear about us? TV show, book Social Media Friend or Family Member Doctor / Health Profesional Other Now, in order to better guide yourself according to your needs, it is time to learn a little more about yourself.What services would you like to receive at the hormone therapy clinic? Female hormone therapy/ Menopause/Pre-menopause Male hormone therapy / Andropause Check the statements that represent you(Required) I have an active cancer that is undergoing treatment (chemo/radio, etc.) I’m pregnant and/or breast-feeding I affirm that I have none of these conditions Check the option that applies to you I’m menopausal and not taking hormones I’m menopausal and already taking hormones As far as I know, I haven’t gone through menopause yet. Check the option that best represents you My cycle is regular but I have several symptoms that could be related to my hormones (hot flashes, night sweats, sleep disorders, etc.). My cycle is irregular, varying in length (too long/too short) with or without spotting/heavy bleeding OR I have stopped menstruating, even without contraception. CAPTCHA
