We need this to match you with a licensed provider in your state.
What sex were you assigned at birth?
We ask this to show you the correct safety and contraindication questions for your physiology. Your answer stays in your chart and only your prescribing provider sees it.
Male
Female
What symptoms are you experiencing?
Select all that apply
Hot flashes
Night sweats
Vaginal dryness
Mood changes
Sleep disruption
Low libido
Brain fog
Joint pain
Weight gain
Fatigue
What is your menstrual status?
I still have regular periods
My periods are irregular
I haven't had a period in over 12 months
I've had a hysterectomy
Do you have recent bloodwork results?
Bloodwork is required before a physician can prescribe hormone replacement therapy. This ensures your treatment is safe and tailored to your body's needs.
Yes, I'll upload my labs (within last 6 months)
No — purchase the HRT Clearance Kit ($124.99, an at-home blood test shipped to your door so our doctors can evaluate and approve your hormone therapy)
Upload your recent lab results
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Click to upload your lab results (PDF, JPG, PNG, or HEIC)
Do any of these apply to you?
These conditions may affect your eligibility for estrogen therapy
None of the below
Breast cancer (current or history)
Endometrial or ovarian cancer
Blood clots (DVT or PE)
Heart attack or stroke
Active liver disease
Unexplained vaginal bleeding
Known blood clotting disorder (e.g., Factor V Leiden)
Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.
Have you had a mammogram in the last year?
Yes
No
I'm under 40 and haven't been recommended one
Do you currently smoke?
Smoking increases the risk of blood clots with estrogen therapy
No, I don't smoke
Yes, I smoke
I recently quit (within 6 months)
Are you pregnant or could you be pregnant?
No
Yes or possibly
Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.
Are you currently taking any medications?
No
Yes
Please list all current medications
Especially thyroid medications, blood thinners, and seizure medications
Do you have a family history of any of these?
None of the below
Breast cancer
Ovarian cancer
Blood clots
Early cardiovascular disease
When was your last women's health clinic visit or OBGYN appointment?
Within the last 12 months
1–2 years ago
More than 2 years ago
Never
Have you ever had an adverse or allergic reaction to hormone replacement therapy?
No
Yes
Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.
Are you of childbearing age or planning to have children?
No
Yes
Have you had a hysterectomy?
No
Yes
When did you have your hysterectomy?
Approximate date is fine.
Did the surgeon remove your ovaries?
No
Yes
Not sure
Do you have a history of moderate or severe PMS symptoms?
No
Yes
Do you have a preferred dosage form?
Your doctor will confirm the safest option for you.
Cream (topical)
Patch
Oral
Vaginal cream
No preference — let my doctor decide
Anything else you'd like your doctor to know?
Share any additional information, questions, or concerns.
This is optional - only include what you think is important
Upload a photo of the front of your government-issued ID.
Driver's license, state ID, or passport. Required for prescriber identity verification.
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Tap to take or upload a photo (JPG, PNG, WEBP, or PDF — HEIC not supported)
Upload a selfie holding your ID.
Hold your ID up next to your face so your prescriber can confirm the ID is yours.
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Tap to take or upload a photo (JPG, PNG, WEBP, or PDF — HEIC not supported)
