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.

VITAMIN IV INFUSION

Vitamin IV Infusion Consent to Deliver
Consent to deliver IVs from pharmacy to Nore Women's Health.

Vitamin IV Infusion Procedure Consent
Informed consent for Vitamin IV Infusion.

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.