This questionnaire must be submitted 24 hours before your scheduled consultation.
Please write down any questions you may have about Prescription Bio-Identical Hormone Replacement
Therapy (Rx BHRT), other medications, or any other questions that come up as you read through the
materials you have received. Bring this question sheet with you to your consultation so you can discuss
this information with your pharmacist. Thank you.
Please list any persons to whom we are permitted to give information to (give name and relationship).