Forms/Policies

Save Time with Our Downloadable Patient Forms

To help make your visit to SynergenX more efficient, our patient forms are available here for download. Simply select the form you need listed below, download the PDF, print it out, complete it and bring it with you to your first visit with SynergenX.

• Men’s Hormone Therapy Intake Form – If you’re a man with symptoms suggesting a testosterone deficiency, download, print and complete this form.
• Women’s Hormone Therapy Intake Form – For women with known or suspected hormonal deficiency, fill out and bring this form with you when you come in.
• Weight Management Intake Form – Whether you’re male or female, download this form and fill it out if you’re coming in to SynergenX for weight loss or weight management care.
• Authorization to Disclose Protected Health Information – This release form and accompanying explanatory page are required by law to protect your private health information. All SynergenX patients should download and complete this form.

If you’ll be unable to complete and bring in the necessary forms, please arrive for your initial appointment 30 minutes before your scheduled visit in order to complete these forms in advance.

If you have any questions or need additional types of forms, call SynergenX at 888.219.7259.