Male Pellet Packet
Multicare Plus
MAK Healthcare, PC
225 Erdman St
Bangor PA, 18013

Personal Data

Primary Care Physician

Present Symptoms

Past Medical History

Please list any medical problems or illnesses you have had or have. Include any hospitalizations and accidents with approximate dates.

Past Surgical History


Please list all prescription medications. Include all over the counter medications, supplements and vitamins.

Family History

Please list all illness (heart desease, stroke, diabetes, hypertension, cancer( Breast, Cervical, Prostate, lung, skin, blood), etc If member is deceased, please list age at death and cause of death if known.
Please remember this information is strictly confidential and will be used only to address your symptoms and/or complaints.

Urological History


Check which of these symptoms are troublesome and have persisted over time.


Check which of these symptoms are troublesome and have persisted over time.

Constitutional / ID / Oncology


Cardio Vascular




Urogical / Renal

MAK Healthcare. PC Bio-Identical Hormone Replacement Program

While numerous safety measure are taken by our physicians and staff. Within the medical community, there are opposing views with respect to the use of bio-identical hormonal replacement therapies. The use of bio-identical hormone does provide ture medical benefit, and is being used at our center to lessen/treat non-life threatening symptoms you have identified as bothersome, undesirable, and frankly unwanted. It is therefore expressely agreed that you're voluntarily participating in this program and bio-identical hormonal replacement regimens, and the use of any medications and/or supplements is undertaken at your own risk. You're voluntarily participating in this program and assume all the risks of injury to yourself that might result. You hereby agree to waive any claims or rights you might otherwise have to pursue legal remidies from MAK Healthcare, PC. And/or Multicare plus, its staff, or treating providers for injury to you on account of involvement in the Bio-identical hormone replacement program. You have carefully read this waiver and fully understand that it is a release of liability.

I accept all terms and conditions of this program.

Maintenance of Pretentative Medicine and Cancer Surveillance

A requirement for acceptance and continuation in the bio-identical hormone replacement program is adherence to routine cancer/prostate screening. You must have routine physical examinations including a PAP, mamogram, prostate examination, and PSA testing. Your signature below indicates that you will comply by obtaining the cancer prostate/screening from your primary care physcian within three months of beginning the bio-identical Hormone Replacement Therapy Program and then according to current screening guidelines which can be obtained, and followed with, your primary care physcian.

I accept all terms and conditions of this program.