TruBalance Patient Referral Form
Please fill out this form to obtain a referral to a BHRT specialist in your area. Please note that all information is kept in strict confidentiality.

First Name: Last Name:
Address: City:
Province: Postal Code:

Daytime Telephone: Cell Phone:


Name of Family Doctor: Family Doctor's Phone:
Family Doctor's Address: Family Doctor's City:

Are you currently on BHRT or TRT therapies?:
If Yes, Which doctor prescribed the therapy?

If Yes, How long have you been on BHRT or TRT therapy?

Are you interested in the HCG weight loss program ?

If there is any additional information that will be important in making a referral, please tell us a little about it here:

Please enter the following code into the box provided: