Templates / BHRT consent form: Free template plus hormone therapy intake form

Hormone Replacement Therapy (HRT)

BHRT consent form: Free template plus hormone therapy intake form

Free PDF • 3 pages, print-ready • Clinician-reviewed

Mark Brave Last updated September 4, 2026 Reviewed by Dr. Vanja Kitanova

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A BHRT consent form records what a patient was told before bioidentical hormone therapy, covering approval status, label risks, monitoring, alternatives and withdrawal rights. This free template is dated to FDA labels checked November 12, 2026, and the patient signs it after the prescriber reviews their intake answers.

The page also carries a full hormone therapy intake form for menopause and testosterone therapy patients, covering history, current hormones, symptoms, vitals and blood tests. Every risk line on the consent names its source and the date it was checked. Review both forms with your medical director and legal counsel before use.

Template details

Template type

Consent form

Format

Printable PDF, 3 pages

Sections

2 sections

Fields to complete

12 fields

Best for

Hormone Replacement Therapy (HRT)

Key takeaways

The free download is a three-page BHRT consent form, and the intake form that comes before it is written out in full on this page.

Compounded hormone preparations, pellets and creams included, are not FDA-approved, and the consent form says so in writing.

Since the FDA’s November 10, 2025 request, labels change product by product, and estrogen-alone products keep the endometrial cancer boxed warning.

Intake answers that match a label contraindication, such as past breast cancer or a blood clot, go to the prescriber before the patient signs consent.

Pabau, the practice management platform we build, sends both forms before the visit and saves the signed copies to the patient record.

What the BHRT consent form covers

A BHRT consent form shows that the patient understood the treatment, its approval status and its risks before the first prescription. The National Academies’ 2020 recommendations ask prescribers to explain the limited evidence and say compounded preparations are not FDA-approved.

Our free download covers the consent part of that paperwork. It runs to three print-ready pages in eight sections, and every risk line names its source and the date it was checked.

We reviewed the BHRT consent forms that rank for this search, and none dated its sources or carried a prescriber signature. Several still describe compounded hormones as natural or FDA-monitored. The form holds these sections:

• Patient and prescriber details: Names, date of birth, patient ID, credentials and the supervising physician or medical director
• Hormones and routes: Estradiol and micronized progesterone by route, plus an FDA-approved, compounded or pellet tick-box for product type
• FDA approval status: The compounding disclosure, what “bioidentical” does and doesn’t mean, and the prescriber’s medical reason for compounding
• Risks: Six label risks, each with who it applies to and a dated source line
• Contraindications: The current label’s list as patient tick-boxes, plus the pregnancy line
• Monitoring: Yearly exams and mammograms, bleeding reports, progestogen use and the saliva-testing statement
• Alternatives and withdrawal: Options discussed, questions answered, the right to withdraw and a neutral payment line
• Signatures: Patient, prescriber and optional witness, with a form version and last-reviewed date

The consent covers estradiol and progesterone for menopause. A patient starting testosterone therapy needs a consent written to that product’s labeling. The intake history lives on this page too, in the hormone therapy intake form further down.

The pellet insertion consent and the prescribing record stay in your own systems. The consent form also carries one practice-policy line on paused refills, which you edit or delete before use.

A medical director usually checks two parts first. The compounding disclosure and the risk table are where older forms contradict current ACOG guidance on compounded hormones and the FDA’s 2025 labeling change.

Risks and contraindications to review before prescribing

Screening is finished before the patient signs the form. The prescriber reviews the intake answers, walks through the risk table with the patient, then checks every contraindication the patient ticked.

The risk table on the consent form

The risk section follows current FDA labeling, with six risk areas, who each applies to and the label it comes from. We used the Vivelle-Dot label (revised October 2026) and the Bijuva label (revised February 2026).

The table makes no efficacy claims. Benefits belong in the prescriber’s conversation, and the consent form records the risks.

Answers the prescriber reviews before treatment

Flag every intake or consent answer that matches a contraindication or warning in the product’s FDA-approved labeling. The prescriber reviews each flag before treatment. Staff do not interpret the answer. They make sure the prescriber sees it.

Section 5 of the consent form lists the estradiol label’s contraindications as patient tick-boxes, so the intake answers get a second check at signing. Labeling is product-specific, and the table uses two current labels checked November 12, 2026.

One is the Vivelle-Dot estradiol patch labeling, revised October 2026. The other is the AndroGel 1.62% testosterone gel labeling, revised July 2025.

Migraine with aura, diabetes and smoking stay on the intake form because prescribers weigh them. Neither label lists any of the three as a contraindication, so the form records them without a flag.

Pregnancy is worded differently on updated labels. The Vivelle-Dot label says hormone therapy for menopause is not indicated for use in pregnancy, so the form uses that wording.

Age and timing go on the record as well. The Menopause Society’s 2022 position statement calls the benefit-risk ratio favorable for women under 60, or within 10 years of menopause onset, without contraindications.

Monitoring instructions to give the patient

Section 6 of the form turns monitoring into commitments the patient signs. Repeat them on a plain-language sheet, so the patient keeps a copy after the visit:

1. Have a breast exam, a pelvic exam and a mammogram every year, unless your prescriber advises otherwise
2. Report any vaginal bleeding to the practice right away, because bleeding after menopause needs evaluation
3. Take a progestogen as prescribed if you have a uterus and use systemic estrogen
4. Keep the follow-up visits and blood tests on your prescriber’s plan
5. Call the practice straight away about loss of vision, severe high calcium, pancreatitis linked to high triglycerides, or jaundice that returns. The label says estrogen is stopped then

The form also rules out saliva and urine hormone tests for setting the dose. The Menopause Society calls them unreliable and does not recommend them.

Reminders keep that schedule on track. Pabau runs recall Workflows by SMS, email or WhatsApp. The workflows skip patients who already have a booking, so nobody gets chased for a visit they have already made.

Treatment records and prescribing details

A prescribing record shows what was prescribed, why, and which consent version covered it. It’s the first document you check when a patient reports a side effect or a compounded product becomes unavailable.

Record the form version with every signature, not only the filed PDF. A patient who signed last spring may hold wording that no longer matches their product’s label.

Pabau stores these entries on the patient record, next to the intake answers, medications and test results. The prescriber sees the last dose and the signed consent before the next appointment.

How to put the form to work in your practice

The download is a single consent form with tick-boxes, blanks and signature lines. Read it against your own prescribing protocol, then roll out one version to every prescriber.

1. Review the form with your medical director and legal counsel, then fill in the version box and last-reviewed date
2. Edit or delete the practice-policy line on paused refills
3. Have the prescriber complete section 2, the hormones, routes and product type, before the patient signs
4. Send the consent form before the visit with the intake form, so the patient reads the risk table at home
5. Review every ticked contraindication, then collect the patient and prescriber signatures
6. Store the signed copy with the prescribing record, plus a separate insertion consent for pellets

Patients re-sign when what they were told changes. Each of these triggers sends the form back out:

• When the hormone changes, such as adding a progestogen
• When the product type changes, such as moving from an FDA-approved product to a compounded preparation
• When the route changes, including a move to pellets, which also needs its own insertion consent
• At the practice’s annual review, alongside the yearly exams the form lists
• When the practice issues a new form version after a label change

The re-sign loop is easiest to see as a cycle, where each trigger sends the patient back to the first step.

For a patient moving to pellets, our guide to hormone pellet insertion covers the procedure side.

Regulation, compounding and FDA labeling

Compounded hormone preparations are not FDA-approved, so the FDA has not reviewed their safety, effectiveness or quality before marketing. FDA-approved estradiol and progesterone products do exist. That is why the form asks for the medical reason whenever a compounded one is used.

Pellets need one extra line. In 2019, the FDA said a 2018 inspection of a pellet company found 4,202 unreported adverse events. The agency could attribute only 61, such as pellet extrusion and cellulitis, to compounded testosterone pellets.

On November 10, 2025, the FDA asked manufacturers to drop cardiovascular, breast cancer and probable dementia language from hormone therapy boxed warnings. The endometrial cancer warning stays on systemic estrogen-alone products.

Cardiovascular and breast cancer information stays in each label’s Warnings section, per the FDA’s labeling-change request. On February 12, 2026, the FDA approved labeling changes to the first six products. Labels then kept changing one product at a time.

The FDA’s updated-labels list named nine products as of October 30, 2026. Prometrium, Divigel, Cenestin, Enjuvia, Minivelle, Vivelle, Vivelle-Dot, Estring and Bijuva are on it. The Climara label still carried the old four-part boxed warning when we checked. A form that quotes one boxed warning for every product is wrong either way.

We call the fix The 2026 label check. It sets common consent-form wording against what the primary sources say now, with replacement wording for each line. Run it against your current form before you swap in this one.

The Menopause Society’s November 2025 response noted that systemic estrogen still carries risks to review in detail. That is the case for keeping the full risk table on the form even as boxed warnings shrink.

What this bioidentical HRT template covers before consent

Before consent, this bioidentical HRT template gives the prescriber a hormone therapy intake form that records history, current hormones, symptoms, vitals and recent blood tests. Intake records the patient’s health and treatment as they stand today. Consent records what the prescriber explained and what the patient agreed to.

What goes on a BHRT intake form?

A BHRT intake form records medical history, medication and hormone use, symptoms and recent blood tests for the prescriber to review before the first visit. The Menopause Society’s 2022 position statement says treatment should be individualized. The statement ties a favorable benefit-risk ratio to age, time since menopause and the absence of contraindications.

A BHRT intake form is an HRT form with one extra question. It asks whether the hormones a patient already uses are compounded or FDA-approved products. The disclosure about compounding then goes on the consent form, and the rest of the intake covers the same ground:

• Patient details: Contact details, emergency contact, primary care provider, preferred pharmacy and insurance.
• Medical and family history: Cardiovascular disease, stroke, blood clots, liver and gallbladder disease, hormone-sensitive cancers and family history.
• Medication and hormone use: Every medicine, supplement and allergy, plus each hormone product’s dose, route and prescriber.
• Group sections: Menopause and reproductive history for one group, and testosterone therapy history for the other.
• Symptoms, vitals and labs: A severity checklist, blood pressure, weight and BMI, and recent blood test results.
• Declaration: The patient’s signature confirming the answers are accurate.

One form for menopause and testosterone patients, or two?

One form serves both groups when it shares a core and adds a short section for each. About two-thirds of the questions apply to every hormone therapy patient: history, medication, vitals, labs and the declaration.

We built this template that way so a practice keeps one form to maintain and one set of answers to review. A patient skips the section that doesn’t apply. Two separate forms tend to drift apart, and a change to the shared questions then has to be made twice.

The hormone therapy intake form, section by section

This HRT intake form has 11 sections, written so you can copy them into your own form as they stand. The form feeds the evidence-based hormone therapy protocol templates your prescribers already follow. It records facts and leaves every treatment decision to the prescriber.

1. Patient details

• Full legal name, preferred name and date of birth
• Sex recorded at birth, asked only where the prescriber needs it for the medicines being considered
• Phone, email and home address
• Emergency contact: name, relationship and phone number
• Primary care provider: name, practice and phone number
• Preferred pharmacy: name, address and phone number
• Insurance carrier, member ID and policyholder name, where the practice bills insurance

2. Reason for visit and goals

• What brings you in today?
• Which three symptoms bother you most?
• What would you like to discuss with the prescriber at your first visit?

3. Medical and family history

Each condition takes a Yes, No or Not sure answer, with space for the year of diagnosis and current treatment.

• Heart disease or heart attack
• Stroke or mini-stroke (TIA)
• Blood clot in a leg or lung (DVT or PE)
• A clotting disorder, such as protein C, protein S or antithrombin deficiency
• High blood pressure
• Diabetes
• Liver disease
• Gallbladder disease
• High triglycerides
• Thyroid disease, and any thyroid medication
• Migraine with aura
• Breast cancer
• Endometrial, ovarian or another hormone-sensitive cancer
• Prostate cancer
• Any other cancer, with the type and year
• Smoking: current, former or never, with the amount
• Alcohol: drinks per week
• Family history: breast or ovarian cancer, prostate cancer, blood clots, heart disease or stroke, with the relative and their age at diagnosis

4. Medication, supplements, allergies and hormone use

• Every prescription medicine: name, dose and how often
• Over-the-counter medicines, vitamins and herbal supplements
• Allergies to medicines, adhesives or other substances, and the reaction
• Current or past hormone use: product name, dose, start and stop dates
• Route: tablet, patch, gel or cream, injection, pellet or vaginal product
• Who prescribed it, and the pharmacy that fills it
• Is the product compounded or FDA-approved? Compounded / FDA-approved / Not sure

5. Menopause and reproductive history

For patients assessed for menopause hormone therapy.

• Menopausal status: regular periods, periods changing, no period for 12 months or more, or not sure
• First day of your last menstrual period
• Hysterectomy: Yes or No, and the year
• Ovaries removed: one, both or neither, and the year
• Could you be pregnant? Yes / No / Not sure
• Current contraception, if any
• Any vaginal bleeding a doctor has not yet explained? Yes / No
• Last mammogram: date and whether follow-up was needed
• Last cervical screening: date and result
• Last bone density scan: date and result, if you have had one

6. Testosterone therapy history

For patients assessed for testosterone therapy.

• Current or past testosterone use: product, dose and dates
• Do you plan to father a child in the next two years? Yes / No / Not sure
• Diagnosed sleep apnea, loud snoring or daytime sleepiness
• Urinary symptoms, such as a weak stream or getting up at night to urinate
• Diagnosed enlarged prostate (BPH)
• Last PSA test: date and result, if known
• Last hematocrit: date and result, if known

7. Symptom assessment

The patient rates each symptom from none to severe. The checklist gives a baseline and is not a validated scale. If your prescribers want a scored, published scale, add it under its own terms rather than adapting these items.

8. Vitals at intake

• Blood pressure: two seated readings, with the time taken
• Weight
• Height
• BMI, calculated from weight and height

9. Blood test results

Record the date drawn, the lab, whether the patient was fasting and the time of day. Then add a row per marker with the result, units and the lab’s reference range. Which markers to order is the prescriber’s call, and our menopause hormone levels template gives a separate log for tracking them.

For testosterone therapy, the product labeling names baseline checks that belong on this section. The rows below come from the AndroGel 1.62% prescribing information, revised July 2025 and checked November 12, 2026.

10. Patient declaration and signature

“I confirm the information on this form is accurate and complete to the best of my knowledge. I will tell the practice if my health or medicines change before treatment starts.”

• Patient signature
• Printed name
• Date

Consent to treatment is not part of this declaration. The patient signs the BHRT consent form in this template’s download after the prescriber has discussed risks and alternatives.

11. Practice line

Print this line at the foot of the form: “Review this form with your medical director and legal counsel before use.” State rules on hormone therapy, supervision and record keeping vary, so the review settles which questions your practice must add.

How does the Intake-to-chart map work?

The Intake-to-chart map pairs each form section with why the practice asks it and where the answer lives in the patient record. It shows the prescriber where to look before the consult. It also shows the practice manager why each question earns its place.

The third column describes Pabau, the practice management platform we build. Where a section’s reason is clinical, the source is named in the row.

Read down the third column and the pattern is plain. Once the form is digital, the prescriber’s prep happens in one record instead of a folder, a lab portal and an inbox. The flow below shows how the form gets there.

How Pabau keeps BHRT intake, consent and prescribing records together

Paper forms tend to sit in one folder, monitoring dates in a diary and lab results in a separate portal. When a patient calls about bleeding, someone has to pull all three together by hand.

With Pabau’s patient intake software, the intake form and the BHRT consent go out before every booking for your hormone therapy service. Patients complete and sign both on their own device, by secure link or through the patient portal.

The answers and the signed consent land in the patient record, so the chart is filled in before the consult. Nobody retypes a medication list from a scanned page. Pabau GO, our iOS app for practitioners, shows the same forms and consents as a checklist on the patient’s care pathway.

Already have an intake PDF you trust? Upload it, and Pabau’s AI rebuilds it as a smart form with its fields and signatures.

Practices building a full hormone service around these forms can see how HRT clinic software handles booking, charting and follow-up in one system. Where testosterone therapy is the main service, Pabau’s men’s health clinic software keeps the same intake, consent and lab records.

What can’t a paper or PDF form do?

A paper or PDF form can’t send itself, file itself or chart a result over time. Each row below pairs a limit of the paper version with the Pabau feature that removes it.

Every Pabau plan includes the core features, and add-ons enhance the experience. Text messages use usage-based SMS credits. Structured onboarding sets your forms and services up with you before the first patient receives them.

Send, sign and store intake and consent

Pabau sends your hormone therapy intake form and BHRT consent form before the first visit and saves the signed copies to the patient record. Your prescriber starts the consult with the history and the signed consent on screen.

Book a demo

Conclusion

A BHRT consent form is only as defensible as its sources and the date on them. A form that quotes one boxed warning for every product, or calls compounded hormones safer, invites the questions it was written to settle.

Pair the consent with an intake form the prescriber reads before the visit, so the risk conversation starts from a complete history. Re-check the FDA’s updated-labels list at each annual review, before a new form version reaches patients.

Book a demo to see Pabau send your intake and consent forms before the first visit and file the signed copies on the patient record.

Continue your research

Tracking hormone levels between visits? Menopause hormone levels template gives prescribers a log for the results recorded at intake.

Moving a patient to pellets? Hormone pellet insertion walks through the procedure that needs its own insertion consent.

Adding testosterone therapy from scratch? How to start a TRT clinic covers licensing, protocols and membership billing for a new testosterone service.

Tracking symptoms between visits? Male monthly hormone cycle template gives patients a monthly log to bring to follow-up appointments.

Frequently asked questions