Hormone Replacement Therapy (HRT)

This referral is intended for collaboration between naturopathic doctors where the referring ND remains the patient’s primary naturopathic provider and is requesting consultation and/or prescribing support related to hormone replacement therapy (HRT).

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Name

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May Hudson Integrative Healthcare contact the patient directly to facilitate booking if an appointment has not been scheduled?

Yes

No

Patient Information

Patient Name*

First Last

Phone*

Email

Additional Information

Prescribing Naturopathic Doctor Being Referred Too*

Dr. Melanie Hudson, ND

Dr. Meaghan Bradica, ND

Dr. Madeleine Elton, ND

Dr. Shelly Linehan, ND

Reason for Referral*

HRT initiation

HRT review or optimization

HRT dose adjustment

Ongoing HRT monitoring

Second opinion

Other

Other Referral Reason - Please Clarify

Specific Question or Goal for Consultation

Relevant Medical History

Please list any relevant diagnoses, risk factors, or health concerns:

Family history relevant to hormones, cardiovascular disease, osteoporosis, or cancer:

Current Medications and Hormones

Current medications and supplements:

Current or previous hormone therapy:*

None

Estrogen

Progesterone

Testosterone

Other

Records Attached

Recent bloodwork

DUTCH Hormone Test

Pelvic ultrasound

Mammogram

Bone density scan (DEXA)

Medication list

Previous HRT records

Other

File

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Max. file size: 5 MB.

Referring Primary Naturopathic Doctor

Referring ND Name*

First Last

Clinic Name

Phone*

Email*

Signature*