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
Financial Policies
Appointment Cancellation, No Show and Late Arrivals Policies
New patients and Established patients review and sign.
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
Procedure Consent
Informed consent for Ultrasound, IUD Removal and/or Insertion, Pellet Insertion, Sonohysterogram.
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.