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Luxe Med LV

Women’s Hormone Optimization Intake

Complete this form so your provider can personalize a plan for perimenopause, menopause, and hormone balance.

Choose your consultation path

SELECTED
✓
Most Patients

✨ Standard Review

  • Free intake submission
  • Provider review within 24–48 hours
  • Pay only if appropriate
SELECTED
✓
Same-Day

⚡ Priority Review — $79

  • Same-day provider review (before 3:00 PM PT)
  • Priority booking access
  • Fee applied to your visit if you proceed

No medications are prescribed without provider review.

Patient Information
Medical History
Check all that apply
Women’s Health
Where are you in your hormone journey?
Symptoms (check all that apply)
Lifestyle & Goals
Primary goals (check all that apply)
Labs
If you have recent hormone labs, please email them to infoluxemedlv@gmail.com.
Consent & Acknowledgment

Copyright © 2026 Luxe Med. All Rights Reserved.

Designed and Developed By: Royal Ink

Treatment Process

  • Registration ($100 fee) includes all appointments (e-consultation or phone consultation), shipping, and supplies for the program.
  • Invoices for the registration fee, questionnaire, and consent forms will be emailed.
  • Program payment invoice will be sent.
  • Injections will be ordered, and dosage and administration instructions will be provided via email.
  • A progress appointment will be scheduled (e-consultation or phone consultation) three weeks later to go over your results and determine next steps in your transformation.

Getting Started

This weight loss program is offered on a monthly basis. A provider will prescribe Semaglutide or Tirzepatide and guide you on how to self-administer the injections at home.

Treatment Process

  • Registration ($100 fee) includes all appointments (e-consultation or phone consultation), lab work, shipping, and supplies for the program.
  • Invoices for the registration fee, weight loss questionnaire, and consent forms will be emailed.
  • Bloodwork will be ordered through Quest Diagnostics once forms are submitted and the deposit is paid.
  • Lab results and the program payment invoice will be sent.
  • Medication will be ordered, and dosage and administration instructions will be provided via email.
  • A progress appointment will be scheduled (e-consultation or phone consultation) three weeks later to go over your results and determine next steps in your transformation.