Hormone Optimization - Male Option

Please complete this form as thoroughly as possible. All information is kept confidential.

Patient Information

Full Name *

Email *

Phone *

Date Of Birth *

Street Address *

City *

State *

Country *

Postal Code *

Gender *

Male

Female

Other

Emergency Contact / Phone *

Occupation

Current Medications

Prescription medications *

Over-the-counter / herbal supplements *

Allergies

Medications *

Food *

Latex *

Yes

No

Family Planning

Planning to have children now or in the future / maintain fertility? *

Yes

No

Testosterone History

Currently taking testosterone (any form)? *

Yes

No

Have you ever used testosterone in the past? *

Gel / Cream

Injection

Pellet

Never

Acknowledgements

I understand that testosterone replacement therapy is elective and will proceed only if deemed appropriate by the provider.

I acknowledge that required laboratory testing must be completed prior to consultation and initiation of TRT.

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