Testosterone Replacement Therapy Intake Form

Full Name

First

Last

Email Address

Phone Number

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Medical History - Check all that apply

Current Medications

Relevant Medical History

Known Allergies

Do you currently use:

Describe your current symptoms (Check all that apply)

What are your goals for testosterone therapy?

Address of risks

Are you aware of potential risks and benefits of TRT?

Consent and Acknowledgement

I acknowledge that the information provided above is accurate to the best of my knowledge.
I understand that further lab testing and evaluation are required before starting testosterone therapy.
I understand that testosterone therapy has risks, including but not limited to fertility reduction, cardiovascular events, and the need for regular monitoring.

Signature (Consent)

Clear Signature

Date / Time

Date

Time

Love Nature by Tyler Moore