I am a...
Patient
Prescriber
Pharmacist
*State
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Why did you start taking hormone therapy?
*Why did you start taking hormone therapy? (Choose One.)
Menopausal hormone replacement
Pre-menopausal hormone optimization/balance
Male hormone optimization
Other
*Which of these forms did you use? ( Select Those Applied )
Cream, gel, or ointment (topically or vaginally)
Pill or capsule
Lozenge or troche
Injection
Suppository
Implantable pellet(s)
I understand my testimonial as outlined above or in the video recorded of me and made on behalf of Alliance for Pharmacy Compounding may be used in connection with publicizing and promoting APC’s campaign to save compounded hormones. I authorize APC to use the brief biographical information I share and the testimonial as defined in this online submission form or by me in this video. I hereby authorize APC to copy, exhibit, publish or distribute the testimonial for purposes of publicizing the campaign to save compounded therapies. The testimonial may be used in printed publications, multimedia presentations, on websites, on social media outlets or in any other distribution media. I agree that I will make no monetary or other claims against APC for the use of the testimonial. I may request that APC remove my testimonial at any time, and APC will do so within 10 days of the request.
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