Let's Get Started:

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New Patient Registration Form

Here you’ll tell Dr. LeCroy, or Jessica Zimmer, PA-C about your health, lifestyle, medical history and Low Testosterone Symptoms.

Your information is secure and will be reviewed by your licensed Physician Assistant and Doctor.

Please call (817) 900-0304 if you have any questions!
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TEXAS RESIDENTS ONLY

As of June 30, 2022, Rise Men's Health will only be treating patients residing in the state of Texas.

We apologize for the inconvenience.
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What is your name?* This field is required.
First Name
Middle Initial
Last Name
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What is your email address?* This field is required.
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Phone number:* This field is required.
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What is your date of birth?* This field is required.
Month
Day
Year
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What is your Address?* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Next, tell us your Biological Sex* This field is required.
Male
Female
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Height and Weight?* This field is required.
Height (Feet)
Height (Inches)
Weight (Pounds)
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Past Medical HistoryHave you been diagnosed with any of the following conditions?
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Surgical History:Click the box and "select all that apply" from the list of surgeries.
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Do you have any of the following Immunizations?Click the box and "select all that apply"
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How often do you consume Alcoholic beverages?
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Tobacco use increases your risk of heart disease. Quitting can decrease your risk. Do you smoke, dip or use any other tobacco products?
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It's important to understand Occupation Risks factors during your initial consult:Do you encounter any of the following at work?
Noise
Fumes
Back Strain
N/A
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Have you had your blood pressure measured in the past 6 months? SYSTOLIC / DIASTOLICA mmHgWhat’s the top number? (SYSTOLIC)
95-120
120-139
140-159
160 or higher
Under 95
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What's the bottom number of your Blood Pressure reading? (DIASTOLIC)What’s the top number? (SYSTOLIC)
65-80
80-90
Over 100
Under 65
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Family medical history can identify people with a higher-than-usual chance of having common disorders, such as heart disease, high blood pressure, stroke, certain cancers, and diabetes. Has anyone in your family been diagnosed with any of the following conditions?
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Family medical history can't predict your future health. It only provides us with important risk factors.Current Health of your family: Poor, Fair, Good
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Are you allergic to any medications?* This field is required.
Yes
No
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Please list medications you're allergic to:* This field is required.
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Are you currently taking any medications, over-the-counter medication, supplements or herbal remedies?* This field is required.
Yes
No
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(If yes, please list medications)
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Have you ever been tested for low testosterone?* This field is required.Have you had a blood test for low testosterone in the past?
YESNO
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Have you ever been diagnosed with low testosterone?* This field is required.Have you had low total testosterone levels on previous lab work?
YESNO
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Have you ever been treated for low testosterone?* This field is required.Have you been prescribed injections, topical, or oral treatments for low testosterone?
YESNO
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Is there anything else the Provider should know?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
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Protected Health Information Disclosure Authorization* This field is required.We are legally obligated to maintain the privacy of your protected health information and to abide by the terms of this agreement. We will provide you the opportunity to review the Notice Of Privacy Practices and ask any questions you may have. We reserve the right to change our privacy practices and apply revised privacy practices to protected health information.I authorize RISE Men's Health to communicate my protected health information (PHI) in the manner indicated below.
Allow detailed personal health information to be left on my voicemail. (Lab results, prescription information, etc.)
Leave a brief message with only a call back number on my voicemail.
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Text Message Consent* This field is required.As of March 31, 2023, businesses must obtain consent to communicate with consumers via SMS text messaging. Rise Men's Health uses text messaging to respond to individual patient questions and concerns. We do not use text messaging for marketing purposes.
I consent to receive text messages from Rise Men's Health
I do NOT consent to receive text messages from Rise Men's Health
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NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information

This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us or to assist with, aid in, or facilitate the collection of data for purposes of utilization review, quality assurance, or medical outcomes evaluation purposes.

Such information may be released to insurance companies, HMO’s and PPO’s, managed care organizations, IPA’s, Medicare/Medicaid, or other governmental or third party payors, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician that is directly or indirectly responsible for your medical care or the payment thereof.

This office will not use or disclose any of your medical and financial information for any purpose not stated above without your specific authorization. You may revoke your authorization at any time.

You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction, you have the right to receive confidential communications of your protected health information, you have the right to inspect, copy, and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office.

You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. No retaliation will be made against you by this office because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.

You may speak with the Office Manager or Privacy Officer to obtain additional information regarding any questions you may have regarding this Notice or to receive a printed copy of this Notice. This Notice of Privacy Practices if effective April 14, 2003.
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Are you using Health Insurance or will you be paying for this visit your self?*Insurance only available in Texas right now. Other states coming soon.
Self-PayInsurance
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Health Insurance* This field is required.Your Insurance Coverage: Is an agreement between you and your insurance company. We agree to file the claim for you and accept the contracted payment. It is your responsibility to remit payment for deductibles, co-pays, and charges not covered by the plan. In order for this office to process your claim, it is important that you present your insurance card at each visit. The card must match the patient being seen. If a problem occurs with your claim, coverage is terminated or denied it is your responsibility to contact your insurance and insure payment or initiate a payment plan with our practice until your insurance problem is resolved. Past due accounts are subject to credit processing. Release of information: I hereby authorize Dr. Kenneth LeCroy or associates in charge of my care to release information contained in my medical records to the insurance company or companies, agents or independent contracts thereof, for the purpose of processing my claims for insurance benefits. Financial agreement: The undersigned hereby agrees that in consideration for services rendered, payment of the account is guaranteed in accordance to the regular rates and terms of Dr. Kenneth LeCroy. The undersigned clearly understands that payment obligation is the responsibility of the patient and or undersigned. Assignment of benefits: I hereby assign to Dr. Kenneth LeCroy or associates associated with my care and treatment any interest and/or benefits provided under my insurance policy or policies. I also understand that any balance not covered by insurance is due and payable by me.
Clear
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Self Pay* This field is required.Financial agreement: The undersigned hereby agrees that in consideration for services rendered, payment of the account is guaranteed in accordance to the regular rates and terms of Dr. Kenneth LeCroy. The undersigned clearly understands that payment obligation is the responsibility of the patient and or undersigned.
Clear
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Enter your insurance information, Group ID and Member IDYou will need to take a picture of your insurance card so keep it handy.
Please Select
Please Select
Aetna
All Savers
Ambetter
Baylor Scott & White
Blue Cross Blue Shield
Cigna
United Healthcare
UMR
Humana
Other
If your insurance is not listed, please select 'Other.' We'll verify with your Group and Member ID.
Member ID is listed on your insurance card.
Group ID is listed on your insurance card.
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Identity Verification: Please load a picture of your drivers license or other government-issued identification.* This field is required.This is for two-step authentication for security purposes. The provider will need to verify your identity before treatment can be provided. Please call 817-900-0304 or email (info@risemenshealth.com) with questions or concerns.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Insurance card: Please load a picture of the front and back of your insurance card.* This field is required.We will need pictures of your insurance card (front and back). Please call 817-900-0304 or email (info@risemenshealth.com) with questions or concerns.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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CONSENT TO TREATMENT* This field is required.Consent to treatment: I hereby grant permission to Dr. Kenneth Lecroy and such assistants as he or they may designate, to perform and administer all treatments and diagnosis, which in their fair judgment may be considered necessary or advisable for the patient’s well being.
Clear
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We can use existing medical records: Are you current being treated for Low Testosterone or do you have recent lab results?* This field is required.We will send a separate e-signature document after we confirm your appointment. Options will include: All Records, Physician Office Notes, ER Visit Records, Laboratory Test Results, Imaging, or Diagnostic Testing
YESNO
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Release of InformationIf you would like to give permission to a spouse, family member, or other person to have access to your medical records. Please list them below:
Name of person
Phone number
Name of person
Phone number
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Initial Telehealth Visit* This field is required.SELECT ONE: if self-pay, select $150. If using insurance, select $20.
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ORDER SUMMARY
Total costUSD
Self-Pay: eTRT Telemedicine Initial ConsultSubscriptions start at $99 per month. We will discuss options after your initial visit.
$150.00Edit
Back
I'm using HEALTH INSURANCE, not self-pay (Texas Patients Only)We charge a holding fee for patients using health insurance. We will verify your benefits before your visit. If you do not have a co-pay, co-insurance, or a deductible, the $20 charge will be refunded after your insurance claim is processed less any copay, coinsurance, or deductible that has been applied.
$20.00Edit
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Optional ADD ON: 10 week supply of our Metabolism Boosting Injections10 week supply of Lipo-B Nutrition Injections - Methionine 25 mg/mL, Inositol 50 mg/mL, Choline Chloride 50 mg/mL, Cyanocobalamin 1 mg/mL 10 mL vial
$160.00Edit
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Total cost $0.00
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New Patient Registration Form

NOTICE OF PRIVACY PRACTICES