Medical Intake Form | Dutch Test Canada

Processing Time Notice: Due to high demand, we are currently experiencing longer processing times. Wait times can be up to 4 weeks. Completing this intake form will place you in our queue, and we'll notify you when we're ready to proceed with your order.

This information helps us provide personalized support throughout your testing process. All information is kept strictly confidential and is used solely for your hormone testing assessment.

Personal Information

First Name *

Last Name *

Email *

Phone

Date of Birth

Biological Sex

Female Male Prefer not to say

Shipping Address

Street Address *

Unit / Apartment (optional)

City *

Province *

Postal Code *

Test Selection

Which test are you interested in? *

Medical History

Current Symptoms & Concerns *

Current Medical Conditions

Current Medications & Supplements

Known Allergies

Recent Surgeries or Procedures

Reproductive Health

Complete this section if applicable to your situation.

Menstrual Status

Regular cycles Irregular cycles Post-menopausal Not applicable

Average Cycle Length

Currently Using Birth Control?

Yes No

If yes, what type of birth control?

Currently Pregnant or Breastfeeding?

Pregnant Breastfeeding Neither

Lifestyle & Wellness

Stress Level *

Low Moderate High Very High

Sleep Quality *

Poor Fair Good Excellent

Exercise Routine

Diet Description

Healthcare Provider (Optional)

Provider Name

Provider Email

I would like my results shared with the healthcare provider listed above

Was this test requested by a practitioner?

Yes No

Additional Information

What are your goals for this testing?

Additional Notes

How did you hear about Dutch Test Canada?

Consent & Agreement

I confirm that the information provided is accurate and complete to the best of my knowledge. * I have read and agree to the Privacy Policy. I understand my health information will be kept confidential. * I have read and agree to the Refund Policy. I understand that all sales are final, no refunds are issued after shipment, and a 10% restocking fee applies to any approved pre-shipment cancellation. * I understand that processing times can be up to 4 weeks and I will be notified when my order is ready to proceed. * I'd like to receive health tips, updates, and promotional offers from Dutch Test Canada. (Optional)