Internal Office Form

Patient Information

First Name *

Last Name *

Phone #

Date of Birth

Location *

CharlestonColumbia

Gender *

FemaleMale

Is this an existing patient or new patient? *

Existing PatientNew Patient

Insurance Information

Primary Policy Insurance Carrier:

Insurance Policy #

Policy Holder Name (if different from patient)

Policy Holder Date Of Birth (if different from patient)

Action Steps

Scheduled a Consultation Cancelled a Consultation Rescheduled a Consultation Only Send CHHC Paperwork Only Send Retreat Paperwork Request a Call Back Scheduled an Additional Service Sold Products Other

Type of Appointment *

BHRTPeptideEmpowerRetreat / Skincare

Consultation Method *

In PersonVirtual

Appointment Date

Appointment Time

Entered By *

Notes

Charleston Location

300 W Coleman Blvd.
Mt Pleasant, SC 29464

Monday - Thursday
9:00 am - 6:00 pm
Friday: Closed

Columbia Location

Monday - Thursday
8:00 am - 5:00 pm
Friday: Closed

*Disclaimer - Individual Results May Vary: The information on this site is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please schedule an appointment with a qualified health provider to answer any question(s) you may have regarding a medical condition. Not everyone qualifies for treatment at Carolina Hormone and Health, Inc. Never disregard professional medical advice or delay in seeking treatment because of something you have read on the Carolina Hormone and Health, Inc. website or social media outlet.