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New Patient
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New Single Select
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Multivitamin Recommendations
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Probiotic Recommendation
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Insulin resistance statement (if glucose hgbA1c high)
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ANS Initial recommendation
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Allergy testing recommendation
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Neuroscan Initial Recommendation
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Risk and Benefits of TRT Statement
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Testosterone dose (NUMBER ONLY)
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test dose (just put number)
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Anastrozole/Arimistane dose
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Dosage of anastrozole/exemestane
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Kisspeptin Dosage
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Lab testing statement
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Theraputic Phlebotomy Statement
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Existing Patient
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TRT Patient
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Testosterone Macros (existing patient)
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Kisspeptin Dosage
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Testosterone dose
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test dose (just put number)
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Anastrozole/Arimistane dose
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Dosage of anastrozole/exemestane
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Donate blood
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Lab draw (If drawn today)
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P-FU-No Change (evaluate next visit)
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P-FU-No Change (peptide recommendation)
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P-FU-No Change (no complaints)
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TRT Plan Free Type
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General Health
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General Health
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Plan for InBody
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Continue Supplements
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Increase Protein, Fat, Carbs
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Nutrition Consult
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Continue diet + lifestyle (leave top two off)
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Exercise
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Lipo-B/B12 injection
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Tri-Amino Injection
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General Health Plan Free Type
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Labs
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Blood draw
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Follow up labs
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Full Wellness Labs
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Theraputic Phlebotomy
|
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Allergy
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Allergy
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Date of service allergy (skin test only)
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Ranging from (list allergic reactions)
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Plan of care (beginning immunotherapy)
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# of units plan of care
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Allergy Follow Up (only use this one if results aren't reviewed same day of test)
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Follow up - recommended immunotherapy/begin
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Allergy Serum Mixing (use when immunotherapy arrives/first bill out)
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Number of immunotherapy units mixed
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Date Mixed
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Plan of Care Mixing Serums
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Weight Loss/Peptides
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Weight Loss/Peptides
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Weight Loss Medication Prescribed
• • •
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Phentermine Protocol Begin
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Diet Journal Plan
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Weight Loss Plan Free Type
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Peptides Prescribed
• • •
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DO NOT USE (RECOMMENDATION ON ADDITIONAL FORM)
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TRT Weekly
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Dose
|
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Anastrozole Amount
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Kisspeptin
|
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Hormonal Cream
• • •
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Notes
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Vitamin Injections
• • •
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Peptides Recommended
• • •
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Supplements Recommended
• • •
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Weight Loss Supplements/Prescription
• • •
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Probiotics
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Weight Gain
• • •
|
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DHEA
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DHEA Frequency
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Theraputic Phlebotomy
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Next Labs Due
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Ancillaries
• • •
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Free Type
|
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CPT/ICD-10 Codes
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Office Visit
• • •
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Common ICD-10
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Cardiovascular Genetic Testing
• • •
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General
• • •
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Hormones
• • •
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Heart Health
• • •
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Allergy
• • •
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Diabetes
• • •
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Metabolic
• • •
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Thyroid
• • •
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Immunology/Infectious Disease
• • •
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ANS
|
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ANS Codes 95943/95923 (any covers both codes)
• • •
|
ANS 95923 (Sudo codes only)
• • •
|
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93923 or 93922 (ABI)
• • •
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