Testosterone Replacement Therapy Intake Form

Full Name

First

Last

Email Address

Allergies History you

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?

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.

Date / Time

Date

Time