Profusions — My Wellness

Welcome

Hormone Replacement Therapy

✦ Potter's House Apothecary

Your care team has released the next steps in your hormone therapy journey. Complete each step below before your pharmacist consultation.

In Partnership With

Profusions Health & Wellness

× Potter's House Apothecary · PCAB Accredited

1-855-PHARXAZ

pottershouserx.com

1

BHRT Patient Intake Form

Complete your hormone health history for Potter's pharmacist

Required

3

Upload Lab Results

Labs within 3 months required. Upload PDF or image.

Required

PDF, JPG, or PNG · max 25MB

4

Schedule Pharmacist Consultation

Book your consult with Potter's House Apothecary · $60/30 min

Locked

🔒

Scheduling opens once your RN has received your labs. You'll be notified in your portal when booking is available.

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My treatments

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My Shots

Medication

Dose (mg)

Injection site

Date & time

Injection pain (0–5)

Notes (optional)

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My Goals

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Health Records

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Your lab orders & results

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Your Wellness Catalog

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Available Times

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All times in MST · 30-minute sessions

Profusions Health & Wellness × Potter's House Apothecary

Hormone Consultation Consent

PCAB Accredited
1-855-PHARXAZ

Thank you for considering Potter's House Apothecary for your Bio-identical Hormone Replacement Therapy. It is important to know that Pharmacists do not have prescribing rights — they will make a recommendation to your provider who will then need to approve the prescription prior to being filled.

We partner with many providers. Should we not have an existing relationship with your provider, it is important that your provider is on board with prescribing bio-identical hormone replacement therapy — if they are not, this could delay the process.

Please be advised there are instances where a provider may delay our prescription recommendation due to diagnostic requirements including but not limited to mammograms or other screenings. Delays or additional cost may be directed to the patient in these instances.

Hormone labs within three months relevancy are required. A completed health intake form is also required to be seen by one of our pharmacists.

Consult Fees:

Up to 30 minutes — $60

Each additional 30 minutes — $60

Adjustment review consult (15–30 min, phone) — $30

A credit card is required to hold your appointment. Payment is due at the time of booking your consultation, paid directly to Potter's House Apothecary.

When the prescription is received, a technician will go over day supply options and cost with you. The medication will not be made until payment is received.

I understand I need to ensure my provider is willing to work with Potter's House Apothecary in receiving/prescribing bio-identical hormone replacement therapy.

Initial here to confirm

I understand the medical information that needs to be provided to proceed with a consultation with Potter's House Apothecary.

Initial here to confirm

I am aware of the consult fee involved. I understand payment is due at the time of booking my consultation.

Initial here to confirm

I understand the medication(s) will need to be made custom for me and will not be done so until after the payment link is paid.

Initial here to confirm

I understand that if an adjustment is needed to my current therapy, my provider may reach out and that may incur a $30 consult fee.

Initial here to confirm

I certify that I have read and understand the information provided above.

Full Legal Name (Signature) *

Date: