Reverse TRT Health Profile

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What is your name?* This field is required.

First Name

Last Name

2

Welcome to Reverse MedicalAge Healthier Age Better

3

Hey! Let's start simple, which of the following best describes your current state?

Feeling Older

Feeling Stressed

Feeling Lethargic

Feeling Unsure

4

Great! What is a good email to have on file?* This field is required.

example@example.com

5

Do any of the following statements apply to you?Check all that apply:

I am just looking to boost my testosterone levels

I have less Muscle Mass & More Belly Fat than i would like

I am not doing as well as I would like at work (Lower Mental Clarity)

I have low energy and or motivation in my life

I have trouble pleasing my partner in the bedroom

6

What is your familiarity with TRT?

None

Just starting to learn

Used to be on TRT

Currently On TRT

7

What past investments have you made in your health?Check all that apply:

Gym Membership/Workout Plans

1:1 Personal Trainer / Online Coaching / Nutritionist

At Home Diet Plans

TRT / HGH / Peptides / Functional Medicine/ etc

Peloton / Tonal / Fitness Technology

I have never invested in my health

8

What is your Health Goal over the next year?Please be specific and explain why you need Dr. Rucker’s help. Goals do not need to be physical goals.

9

What do you feel was your Biggest Obstacle to achieving your goal AND/OR sustaining it? Please provide as much detail as you can* This field is required.Biggest obstacle in your way. Don't think too hard, just write what comes to mind

10

We try to make working with Dr. Rucker Affordable for all Budgets (Plans start at $100 monthly, As well as exclusive pricing on single order peptides). If you like what you hear from him during your call how quickly are you ready to start? We offer Longer Term Programs with additional savings.

Yesterday

Today

Not Ready Yet

Would like More Info First

11

When is your Birthday?* This field is required.We need your date of birth due to reverse being a medical prescription.

12

Where are you Located?* This field is required.Example: Sarasota, Florida

13

Which Type of Plan Interests You?This helps Dr. Rucker propose the most realistic option for your Health & Wallet!

I want basic TRT Delivered.

I want THE WORKS! Peptides, Hair Compounds, ED, Etc

14

What Other Treatments Would You Like to Ask Dr. Rucker About?Dr. Rucker can provide custom bundles that are tailored to you if needed.

Medical Marijuana (FL Residents only)

Peptides

ADHD

Erectile Dysfunction Treatment

Hair Loss Treatment

Other

15

Have you ever had labs taken for Low Testosterone? If you are coming from another TRT Clinic we will provide a Discount* This field is required.

Yes

No

I Don't Remember

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If Yes, What was the Result?* This field is required.

Low Testosterone

I Don't Remember

Normal Levels

I Would Like New Labs

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You can upload your labs here for Dr Rucker if you have them on handYou can also send you labs at any time to Labs@reversepractices.com

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

18

Were you told about us?If Yes, please name them here

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If you would like New Labs, we can send you a lab script to your email. We pay $20 towards your $30 Testosterone Level Test

I want new Labs!

Want to speak to Dr. first

Not at this time

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ONE LAST STEP! Enter your phone number & Click NEXT to have a Success Coach reach out to you for a call with Me. On this call, we will see if you are a good fit and give you a full breakdown of our program. * This field is required.I will also reach out by texts to reach your needs sooner! - Dr. Rucker

Please enter a valid phone number.

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I Can't Wait To Learn More About Your Goals!-Dr Rucker