Patient Forms | Nore Women's Health

New Patient Packets

New Female Patients (Menopausal)
For female patients experiencing menopausal symptoms.

  • Patient Information
  • HIPAA Release
  • Menopause Rating Scale

New Female Patients (Not Menopausal)
For female patients not experiencing menopausal symptoms.

  • Patient Information
  • HIPAA Release

New Male Patients
For male patients.

  • Patient Information
  • HIPAA Release
  • ADAM Questionnaire

New Aesthetics or Vitamin Therapy Patients
For female or male patients seeking only Aesthetics or Vitamin Therapy , including Micronutrient Testing, Vitamin IV Therapy, Vitamin Shots and Vitamin Supplements.

  • Patient Information (Shortened)
  • HIPAA Release

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.

Surgery Scheduling

Surgery Scheduling Policy
Signature required before scheduling surgery.

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.

Aesthetics

Botox and Filler Consent
Informed consent for injection of Botox® Cosmetic, JUVEDERM® XC, JUVEDERM® Ultra XC, JUVEDERM VOLLURE™ XC, JUVEDERM VOLUMA® XC and/or JUVEDERM VOLBELLA® XC.

Other Procedure Consents

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.

CORONA VIRUS UPDATE

We are doing all we can to keep our patients healthy and safe during this time and are taking extra precautions to help reduce the spread of Coronavirus.

We are available to see patients in office and online on Tuesday and Thursday, but we are available to answer your call Monday through Friday.