Testosterone Replacement Therapy

APPOINTMENT REGISTRATION

TESTOSTERONE REPLACEMENT THERAPY
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Medical History
Do you have any of the following health conditions?

Pulmonary HTN Use Current Smoker Kidney Disease Hepatic Impairment Hypertension Hypotension BP Hypovolemia Cardiac Conditions Aortic Stenosis Idiopathic Hypertrophic Subaortic Stenosis IHSS Autonomic Dysfunction Congestive Heart Failure Heart Attack History Stroke Arrhythmias Coronary Revascularization Coronary Artery Diseases Diabetes Mellitus Hyperlipidemia Non-arteritic Anterior Ischemic Optic Neuropathy History Low Optic cup-to-disc Ratio Hereditary Degenerative Retinal Disorders Penile Deformities Conditions Predisposing to Priapism (unwanted, persistent erection) Sickle Cell Disease Bleeding Risk Other
Patient Questionnaire
Please indicate the symptoms most concerning?

Unable to have erection Unable to keep erection Erections are not strong enough to engage in intercourse Other
When did your symptoms start? (an estimate is ok)

Month Day Year
Please indicate any/ all medications you are currently taking *
Please list all allergies, or type N/A if you have none *
Billing & Payment
CASH PAY ONLY. Do you understand that you will not be able to use insurance for your appointment? *

Yes

Please purchase the visit that is best suitable for you

Testosterone - New Patient consultation The initial consultation includes a complete history and physical. In addition, and we will go through each lab one by one with you so you understand where you stand with your health. This visit is more than just a testosterone consultation, it includes vitamin and supplement counseling as well as additional services such as growth hormone optimization, weight loss, and primary care if interested. Initial cost also includes: Unlimited visits and consultations, 1st month of Testosterone injections and B12 injections.

$ 285.00

Testosterone Optimization Therapy If you qualify and wish to proceed with testosterone optimization therapy, you will have weekly injections and have follow up visits scheduled every 8-12 weeks depending on your progress. $200 Monthly recurring cost includes: Unlimited visits and consultations, weekly testosterone injections and B12 injections, and anastrozole(Medication to control estrogen levels if they increase.

$ 200.00

Testosterone - Weekly Shot

$ 85.00

Total

$ 0.00

Credit Card

By signing below, I hereby consent that I have read and agree to the following statements.

1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by this clinic and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at this clinic.

2. I agree to be contacted via email or SMS with information related to my visit, like a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family.

3. I authorize payment of medical benefits to this clinic or their designee for services rendered.

4. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.
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Dear Patient,

Thank you for completing the form.

Please do not forget to schedule your appointment. We are happy to accommodate you and schedule the most convenient time for you!
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