Forms

PATIENT FORMS

We know you’re busy. That’s why we use online forms that are mobile and desktop friendly. Nothing to print, scan or email. All of our forms are HIPAA compliant so your sensitive information is protected.

NEW PATIENT PACKETS

Welcome to Nore! New patients can speed up their check-in process by completing forms prior to their first visit.

Menopause Patients

This packet includes the Patient Information, HIPAA Release and Menopause Rating Scale.

Other Female Patients

This packet includes the Patient Information and HIPAA Release.

Male Patients

This packet includes the Patient Information, HIPAA Release and ADAM Questionnaire.

PATIENT INFORMATION

Patient Information

New patients provide personal information and medical history. Established patients update annually.

Menopause Rating Scale

Measures the severity of aging-symptoms and their impact on quality of life. Developed by the Berlin Center for Epidemiology and Health Research.

RELEASES

HIPAA Release

Authorization to share health information with other individuals.

Medical Information Release

Authorization to request or release your medical information.

Patient Testimonial Release

Authorization for Nore to use your testimonial on our website and promotional materials.

HORMONE THERAPY

Hormone Therapy Consent

Informed consent for Menopause Hormone Therapy (MHT).

MONALISA TOUCH®

MonaLisa Touch® Screen

Survey of symptoms.

MonaLisa Touch® Questionnaire

Survey of treatment progress.

MonaLisa Touch® Consent

Informed consent for CO2 Fractional Laser treatment.

THERMIVA®

ThermiVa® Consent

Informed consent for ThermiVa® radio-frequency treatment.

O-SHOT®

O-Shot® Consent

Informed consent for Vaginal Submucosal/Suburethral, Clitoral, and/or Labial Injection of Platelet Rich Plasma (PRP) and Administration of Local Anesthesia.

URINARY INCONTINENCE

Urinary Incontinence Screen

Survey of symptoms.

MALE PATIENTS

Male Patient Information

New patients provide personal information and medical history. Established patients update annually.

ADAM Questionnaire

The Androgen Deficiency in Aging Males (ADAM) test is an easy way to answer questions about your sexual health, which can help to see if you need your testosterone level checked.

Testosterone Therapy Consent

Informed consent for testosterone therapy.

Skip to content