bioidentical hormone replacement therapy bhrt eligibility intake form

Take the first step to improving your long term health

This intake questionnaire helps us determine your eligibility to join Dr. Elisabeth Crisci’s practice.

Your personal information is protected under the Canadian Personal Information Protection and Electronic Documents Act (PIPEDA).

DATA PRIVACY: Your personal information is used only to determine your eligibility for our treatment services, and is stored in a secured cloud database. If it is determined that you are not eligible, you can request the deletion of your personal data.

General Eligibility Form

eMail and AgreementStep 1 of 11

First Name: (As it appears on your health card.) *

Last Name: (As it appears on your health card.) *

Email: *

Mobile phone: *

This allows us to send you security and login updates.

Do you agree to receive subsequent email communications from Pacifica MD? *

I agree.

British Columba resident: *

I confirm that I am a resident of British Columbia, Canada.

Dr. Crisci is only licensed in the Province of British Columbia, Canada.

Address *

Address Line 1

City

Zip / Postal Code

Sex at birth: *

Female
Male

Please note that BHRT treatments from Dr. Crisci are designed to restore and balance natural hormones for women aged 20 to 65, and men aged 40 and older. These hormone treatments are not designed for those wishing to alter gender identity.

Date of birth *

Symptom Questionnaire for Women

Breast tenderness *

None
Mild
Moderate
Severe
Very severe

Physical exhaustion / fatigue *

None
Mild
Moderate
Severe
Very severe

Sleep problems *

None
Mild
Moderate
Severe
Very severe

Decline in drive or motivation *

None
Mild
Moderate
Severe
Very severe

Anxiety *

None
Mild
Moderate
Severe
Very severe

Joint and muscular symptoms (aches and pains) *

None
Mild
Moderate
Severe
Very severe

Memory difficulties *

None
Mild
Moderate
Severe
Very severe

Low sex drive *

None
Mild
Moderate
Severe
Very severe

Night sweats *

None
Mild
Moderate
Severe
Very severe

Hair changes / thinning *

None
Mild
Moderate
Severe
Very severe

Brittle nails *

None
Mild
Moderate
Severe
Very severe

Dry skin / loss of skin tone *

None
Mild
Moderate
Severe
Very severe

Excess weight or difficulty losing weight, especially around the waist *

None
Mild
Moderate
Severe
Very severe

Feeling cold all the time *

None
Mild
Moderate
Severe
Very severe

Difficulty building or maintaining muscle *

None
Mild
Moderate
Severe
Very severe

Bladder problems / incontinence *

None
Mild
Moderate
Severe
Very severe

Discomfort with intercourse / vaginal dryness *

None
Mild
Moderate
Severe
Very severe

Hot flashes *

None
Mild
Moderate
Severe
Very severe

Note: the above symptoms are typical of hormonal imbalances, which are increasingly common as we age. Hormonal imbalances can not only deprive you of your quality of life and vitality, but can also increase your risk for coronary artery disease, cerebrovascular disease, osteoporosis, cognitive decline, insulin resistance, and diabetes. It can also lead to genitourinary symptoms such as incontinence, vaginal dryness and atrophy, and discomfort with intercourse.

Symptom Questionnaire for Men

Physical exhaustion / fatigue *

None
Mild
Moderate
Severe
Very severe

Decline in drive or motivation *

None
Mild
Moderate
Severe
Very severe

Low sex drive *

None
Mild
Moderate
Severe
Very severe

Brittle nails *

None
Mild
Moderate
Severe
Very severe

Bladder problems / incontinence *

None
Mild
Moderate
Severe
Very severe

Difficulty achieving or maintaining an erection *

None
Mild
Moderate
Severe
Very severe

Sleep problems *

None
Mild
Moderate
Severe
Very severe

Joint and muscular symptoms (aches and pains) *

None
Mild
Moderate
Severe
Very severe

Night sweats *

None
Mild
Moderate
Severe
Very severe

Dry skin / loss of skin tone *

None
Mild
Moderate
Severe
Very severe

Difficulty building or maintaining muscle *

None
Mild
Moderate
Severe
Very severe

Anxiety *

None
Mild
Moderate
Severe
Very severe

Memory difficulties *

None
Mild
Moderate
Severe
Very severe

Hair changes / thinning *

None
Mild
Moderate
Severe
Very severe

Feeling cold all the time *

None
Mild
Moderate
Severe
Very severe

Excess weight or difficulty losing weight, especially around the waist *

None
Mild
Moderate
Severe
Very severe

Mild or no symptoms are not enough to qualify for this program. Thank you for your participation.

Many of the above symptoms are typical of hormonal imbalances which are increasingly common as we age. Hormonal imbalances can not only deprive you of your quality of life and vitality, but can also increase your risk for coronary artery disease, cerebrovascular disease, osteoporosis, cognitive decline, insulin resistance, and diabetes.

Treatment Cost Statement

Dr. Crisci, in addition to her 20 years of clinical experience, has been formally trained in bioidentical hormone replacement therapies by a variety of prestigious associations such as the Menopause Society, the American Academy of Anti-Aging Medicine (A4M) and others. She offers a comprehensive, evidence-based approach to hormone optimization to set you on the best possible trajectory as you age.

Despite holding an unrestricted license by the College of Physicians and Surgeons of BC, BHRT is considered ‘Complementary and Alternative Medicine’ which means that the clinical care and associated investigations (testing) are not covered by the Medical Services Plan of BC (your health card).

The pricing for this treatment for the first 12 months is $2999.00 + GST CAD, which includes an initial personalized 45 minute consultation with Dr. Crisci and all medical visits, Lifelabs testing of main sex (gonadal) hormones and laboratory administration fees (value of approximately $800 per year), and 15% off pelleting procedures if chosen.

Insurance coverage statement *

I understand that BHRT constitutes a type of care that is considered complementary and alternative, and that I am responsible for payment. It is also my responsibility to verify ahead of time with my private insurance if this type of care is covered.

A payment plan is available. Please inquire in advance if you have questions.

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

Do you currently have, or have had in the past, any of the following: *

Breast cancer
Skin Cancer
Cancer, other
Blood clot (e.g. in legs or lungs)
Blood or clotting disorder such as polycythemia vera, factor V leiden deficiency or hemochromatosis
TIA / stroke
Heart attack / angina
None of the above

Because of your answer to the above question, please use the blue button on the bottom of this page to book a complimentary 15-minute call with Dr. Crisci to determine if you are a suitable candidate.

Because you’ve answered yes to the above, please provide more information: *

Has a healthcare provider ever told you that hormones were not recommended in your situation? *

Are you currently followed by a specialist for a medical issue? If yes, please describe below. *

Are you currently pregnant, thinking of possibly getting pregnant, trying to conceive or breastfeeding? *

Because of your answer to the above question, please use the blue button on the bottom of this page to book a complimentary 15-minute call with Dr. Crisci to determine if you are a suitable candidate.

If you are of childbearing age, what is your method of contraception? *

The purpose of this questionnaire is to ensure that you are a good candidate for Dr. Crisci’s practice. Please answer the following questions as accurately as possible:

Do you currently have, or have had in the past, any of the following: *

Prostate cancer
Skin Cancer
Cancer, other
Blood clot (e.g. in legs or lungs)
Blood or clotting disorder such as polycythemia vera, factor V leiden deficiency or hemochromatosis
TIA / stroke
Heart attack / angina
None of the above

Because of your answer to the above question, please use the blue button on the bottom of this page to book a complimentary 15-minute call with Dr. Crisci to determine if you are a suitable candidate.

Because you’ve answered yes to certain of the above, please provide more information:

Has a healthcare provider ever told you that hormones were not recommended in your situation? *

Are you currently followed by a specialist for a medical issue? If so, please give details. *

Are you currently trying to conceive? *

Because of your answer to the above question, please use the blue button on the bottom of this page to book a complimentary 15-minute call with Dr. Crisci to determine if you are a suitable candidate.

We encourage all our prospective patients to explore our FAQs here on our website, and participate in one of Dr. Crisci's live webinars, to ensure that they are aware of her credentials as a medical doctor, expertise, clinical approach and care philosophy prior to deciding to join her practice.

We value your decision-making process regarding the start of your treatment. Please select the option that best describes your situation:

I have some questions or concerns that I would like to discuss with Dr. Crisci in a short 15 min. video consultation before making a decision. I understand this may delay the start of my treatment by a few weeks or months.
I am ready to proceed with payment and begin my personalized treatment plan within the next two weeks. I wish to proceed to payment of my initiation fee, after which I will be contacted to book my initial consultation and will receive my first lab requisition, which I will take to Lifelabs at least one week prior to my appointment.
I need more time to consider my options, and am not ready to make a decision at this time. I will reach out when I have reached a decision.

Because of your answer to the above question, please use the blue button on the bottom of this page to book a complimentary 15-minute call with Dr. Crisci to determine if you are a suitable candidate.

Please list your current prescription medications including dose, frequency and route. *

Please list all your supplements, indicating doses and frequency. *

Do you have any allergies? Please describe to what and what is the reaction. *

What are your hopes and expectations with regards to joining Dr. Crisci’s practice? *

Are you ready to submit your profile?

I hereby confirm that the information provided in this medical questionnaire is accurate and complete to the best of my knowledge. I understand that withholding any relevant information about my current or past medical history may affect my eligibility to become Dr. Crisci’s patient. Please use the “previous” button to review and change any sections before submitting.

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