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    • Hormonal Imbalance
    • BioTE Pellet Therapy for Women
    • BioTE Pellet Therapy for Men
    • Incontinence Care
    • Birth Control and Contraception
    • Robotic daVinci Surgery
    • Obstetrics
    • Gynecology
    • Well Woman Visit
  • Patient Resources
  • Contact Us

1252 Harwood Road

Bedford, TX 76021

Call Us: (817) 284-1496

www.charlessafelymd.com
Call Us: (817) 284-1496
Patient PortalPortal Icon
  • Home
  • About Us
  • Services

    • Hormonal Imbalance
    • BioTE Pellet Therapy for Women
    • BioTE Pellet Therapy for Men
    • Incontinence Care
    • Birth Control and Contraception

    • Robotic daVinci Surgery
    • Obstetrics
    • Gynecology
    • Well Woman Visit
    Patient Portal
  • Patient Resources
  • Contact Us

Patient Resources

Download patient forms by clicking the links below.

Patient Forms

Once completed, print your forms and give them to the front desk upon check-in OR email completed forms to csafelymd@gmail.com

Patient Information Form

Patient Information Form

Patient History Form

Patient History Form

HIPAA Authorization of Use and Disclosure

HIPAA Authorization of Use and Disclosure

Financial Policy

Financial Policy

Only if Pregnant-Ob Questionnaire

Only if Pregnant-Ob Questionnaire

Post and Pre-Op Instructions

Outpatient Post-op Instructions

Outpatient Post-op Instructions

Major Post-op Instructions

Major Post-op Instructions

General Surgery Pre-op Instructions

General Surgery Pre-op Instructions

BioTE for Women Forms

Commonly Asked Questions

Commonly Asked Questions

Female BHRT Checklist

Female BHRT Checklist

Female Hormone Replacement Fee Acknowledgment

Female Hormone Replacement Fee Acknowledgment

Female Patient Questionnaire History

Female Patient Questionnaire History

Female Pellet Acknowledgment

Female Pellet Acknowledgment

HIPAA Inform and Consent Form

HIPAA Inform and Consent Form

Insurance Disclaimer

Insurance Disclaimer

Symptom Sheet Female and Male

Symptom Sheet Female and Male

BioTE for Men Forms

Commonly Asked Questions for Males

Commonly Asked Questions for Males

HIPPA Inform and consent Form

HIPPA Inform and consent Form

Insurance Disclaimer

Insurance Disclaimer

Male Hormone Replacement Fee Acknowledgment

Male Hormone Replacement Fee Acknowledgment

Male Patient Questionnaire History

Male Patient Questionnaire History

Male Testosterone Acknowledgment

Male Testosterone Acknowledgment

Symptoms Sheet

Symptoms Sheet

Other

Medical Records Release TO Dr. Safely

Medical Records Release TO Dr. Safely

Medical Records Release FROM Dr. Safely

Medical Records Release FROM Dr. Safely

www.charlessafelymd.com
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www.charlessafelymd.com

Copyright © 2023 Charles Safely MD
All rights reserved.

IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice. Statements made on this website have not been evaluated by the Food and Drug Administration. The information contained herein is not intended to diagnose, treat, cure or prevent any disease.

1252 Harwood Road,
Bedford, TX 76021

Call Us: (817) 284-1496

Copyright © 2023 Charles Safely MD
All rights reserved.

IMPORTANT! All information presented in this website is intended for informational purposes only and not for the purpose of rendering medical advice. Statements made on this website have not been evaluated by the Food and Drug Administration. The information contained herein is not intended to diagnose, treat, cure or prevent any disease.


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