I am requesting this consultation by my own choice, and assume all responsibility for my use of Biologically Identical Hormone Replacement Therapy (BHRT). I acknowledge that I am legally responsible for and aware of the potential side-effects associated with BHRT. I understand that no doctor, pharmacist, or administrative personnel can guarantee that BHRT will provide the results I seek. I hereby release Wells Pharmacy, all its employees and pharmacists from any and all liability whatsoever associated with or connected to my Biologically Identical Hormone Replacement Therapy (BHRT) consultation and/or use of BHRT. 

I have been advised in this hormone self-assessment about the increased risks of heart disease, myocardial infarction, stroke, and breast cancer possibly associated with the use of hormone therapy. I am currently under the medical supervision of a primary care physician. I fully understand that it is my responsibility to have an annual physical examination along with appropriate laboratory testing. I I have answered truthfully all of the questions on this questionnaire.