Hormone Therapy Intake Form

Complete the HIPAA compliant Hormone Therapy Intake Form to start your journey with Holy City Healthcare Consultants. This form helps our licensed medical team understand your health history, symptoms, and goals so we can provide safe and effective hormone therapy tailored to your needs. Whether you are seeking support for energy, mood, sleep, or overall wellness, your comfort and safety are our top priorities from the very beginning.

Click the button below:
Open Secure Hormone Therapy Form
The form takes about 10 minutes. Please complete it in one sitting.

Why it opens in a new tab

For privacy and security, the form is hosted on Paubox rather than our website. This keeps your information protected and ensures it is transmitted securely.

What you will need

1. Contact information and date of birth
2. Brief medical history and current symptoms
3. Current medications and supplements
4. Allergies and relevant past procedures
5. Primary care or referring provider (if any)

How we use your information

We use your answers only to review safety, tailor your plan, and coordinate care. We do not sell patient data. For more details, see our Privacy Policy

Need help?

If you have questions or need assistance, email clientservices@holycityhc.com
or call (843) 703-1049.
If the button does not work, you can click on the link below to open form in new tab:
https://next.paubox.com/forms/HolyCityHealthcareConsultants/form/ca49bad5-50af-408c-9bfa-508af25e72bf