$25 First Month Form

1

Hey! Let's start simple, which of the following best describes your current state?* This field is required.

Feeling Older

Feeling Stressed

Feeling Lethargic

Feeling Unsure

2

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

3

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

4

What is your name?* This field is required.

First Name

Last Name

5

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

example@example.com

6

Are you still interested in learning more about TRT Therapy and Dr. Rucker's approach?

Yes! Let's Talk!

No I'm no longer interested.

I'm not sure, need more info.

I would like to keep filling out the form.

7

Become One Of Dr. Rucker's Success Stories

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

Hear from a current patient:

11

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

12

We are happy to offer you a $10 Lab & Consultation with Dr. Rucker. We pay $16 of your $26 Lab Order. After your $10 payment we will send you a lab order that can be filled at any quest in the nation. When would you like your lab order?

Yesterday

Today

Not Ready Yet

Would like More Info First

13

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

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.

Hair Loss Treatment

Peptides

ADHD

Erectile Dysfunction Treatment

Medical Marijuana (FL Residents only)

15

ONE LAST STEP! Enter your phone number & Click NEXT to have a Success Coach text/email your lab order ($26 checkout link) A lab order to your email does not require you to purchase anything until you decide. * This field is required.I will also reach out by texts to reach your needs sooner! - Dr. Rucker

Please enter a valid phone number.

16

Why We Ask For This Profile