Hormone Replacement Therapy New Patient Intake

Feel Ideal 360 Aesthetic and Wellness Clinic

660 W Southlake Blvd. Suite 100

Southlake, Texas 76092

Office: 972-656-1200

Fax: 972-656-1500

EMAIL: info@feelideal360.com

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Who referred you?

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State/Province

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Zip Code

Hormone Therapy Intake Costs

Lab Review + Blood Work (no insurance coverage):

$175 HRT Lab Review Consultation Fee
$475 Blood Work Fee (ordered by Feel Ideal 360)

Total: $650

Lab Review Only (with current labs or insurance-covered labs):

$175 HRT Lab Review Consultation Fee

Total: $175

Have you completed lab work within the last 12 months?

Please choose one below:

Yes, I have current lab work.
No, I will need to order new lab work.

Upload your lab work here:

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Do you have insurance to cover the cost of lab work?

Please choose one below:

Yes, my insurance will cover the cost of lab work.
No, I don’t have insurance. No worries! Feel Ideal 360 has you covered and can order your lab work for you in the amount of: + $475.00

Insurance Information

Insurance Carrier

Member Number

Group Number

Please upload an image of the front of your insurance card:

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Back image of insurance card:

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HRT SYMPTOM QUESTIONNAIRE

Depressive Mood

(please select one)

Never
Mild
Moderate
Severe

Fatigue

(please select one)

Never
Mild
Moderate
Severe

Memory Loss

(please select one)

Never
Mild
Moderate
Severe

Mental Confusion

(please select one)

Never
Mild
Moderate
Severe

Decreased Sex Drive/Libido

(please select one)

Never
Mild
Moderate
Severe

Sleep Problems

(please select one)

Never
Mild
Moderate
Severe

Mood Changes & Irritability

(please select one)

Never
Mild
Moderate
Severe

Tension

(please select one)

Never
Mild
Moderate
Severe

Migraine/Severe Headaches

(please select one)

Never
Mild
Moderate
Severe

Difficulty To Climax Sexually

(please select one)

Never
Mild
Moderate
Severe

Bloating

(please select one)

Never
Mild
Moderate
Severe

Weight Gain

(please select one)

Never
Mild
Moderate
Severe

Breast Tenderness

(please select one)

Never
Mild
Moderate
Severe

Vaginal Dryness

(please select one)

Never
Mild
Moderate
Severe

Hot Flashes

(please select one)

Never
Mild
Moderate
Severe

Night Sweats

(please select one)

Never
Mild
Moderate
Severe

Dry & Wrinkled Skin

(please select one)

Never
Mild
Moderate
Severe

Hair Is Falling Out

(please select one)

Never
Mild
Moderate
Severe

Cold All The Time

(please select one)

Never
Mild
Moderate
Severe

Sweating All Over The Body

(please select one)

Never
Mild
Moderate
Severe

Joint Pain

(please select one)

Never
Mild
Moderate
Severe

FAMILY HISTORY

Heart Disease

(please select one)

Diabetes

(please select one)

Osteoporosis

(please select one)

Alzheimer's Disease

(please select one)

Breast Cancer

(please select one)

You are about to begin feeling better and taking control of your hormone journey!

When you complete your HRT Patient Intake Form and submit your $175 Hormone Therapy Lab Review Consultation Fee (NOTE: not covered by insurance), here’s what happens next:

Your intake process officially begins.
A member of our clinical team will confirm your lab order and ensure it has been submitted to the appropriate testing facility.
We’ll notify you once your labs are in progress or completed.
Your VIRTUAL HRT Lab Review appointment with Dr. Straface will be scheduled.
You will receive an email with the link to access your meeting with Dr. Straface virtually.
During your consultation, Dr. Straface will review your results in detail and design your personalized hormone therapy plan.

Please note, the $175 fee is Dr. Straface’s professional consult fee and covers your in-depth virtual appointment, thorough lab review, and tailored treatment plan.

Ongoing Hormone Therapy Costs

Once your consultation and lab review are complete, you’ll be ready to begin treatment. Ongoing pellet therapy is simple and predictable:

Female Pellets: $378 every 3–4 months
Male Pellets: $788 every 6 months

This transparent pricing ensures you know exactly what to expect as you continue your personalized hormone therapy journey.

Medical Disclaimer

Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at Feel Ideal 360.

After reviewing your information, or during the e-visit, it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated.

All pertinent communication related to the e- visit encounter will be documented in the patient’s medical/health record, and made available upon appropriate request. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Any additional care, tests, or examinations will be at the sole cost of the patient.

As with any medical service or treatment, there are risks; an e-visit is no different. Because this visit is electronic and not in person, patient acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit, patient agrees to accept the outcome-even if it is undesirable. In the event of an undesired outcome, the patient releases all physician and clinic liability.

****untraditional methods of treatment.

In the event that you cancel your telemedicine appointment within the 48-hour call period, please be aware that a 3% processing fee will apply with your refund.

I acknowledge I am paying for a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

In addition, you agree to abide by our office's routine policies including any policy related to litigation.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Straface to proceed with our telemedicine visit.

Date

I agree that if I do not attend my scheduled appointment, I will be charged a $75 cancellation fee.

Please agree here:

Yes, I agree.

Billing Address

Address Line 1

Address Line 2

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State/Province

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Zip Code

Sub Total

$175.00

TOTAL

$175.00

Payment Method

Credit Card - Square

Hormone Replacement Therapy New Patient Intake

Hormone Therapy Intake Costs

Ongoing Hormone Therapy Costs

Your Wellness Journey Has Begun – Next Steps Inside