Telehealth Mens Health/HRT Intake (Official)

Name*

First NameLast Name

Date*

Date

Cell Number*

Area CodePhone Number

Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Prescription shipping Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date

Gender at birth*

MaleFemale

Please Select which Therapy you purchased and wish to use*

Testosterone InjectableTestosterone oral (kyzatrex)

Height (ft)*

Weight (lbs)*

Blood Pressure (mmHg)*

Do you have any allergies? If none please list NA*

Are you taking any medications currently? If none Please NA*

Any meds including supplements

Existing Medical Problems/Conditions If none please list NA*

Previous hospitalization in the last year If no please list NA *

Provide the reason and treatment

Do you have any history of cancer of any kind?If none Please list NA *

Do you have any history of blood clots in your legs (DVT)or lungs (pulmonary embolism)? If none please list NA *

personal/Family History Illnesses*

Please choose Testosterone treatments you purchased. These must match what you purchased*

TestosteroneEnclomipheneNandrolone DecoanateKyazatrex

System Review*

	Yesl	No	Notes/Remarks
Erectile Dysfunction
Decreased Libedo (sex drive )
Brain Fog/Decreased mental clarity
Loss of memory/trouble concentration
Fatigue/Decreased Energy
Depression
Amxiety
Irritability
Trouble sleeping/insomia
Decreased self confidence
Low motivation
Weight gain/increased body fat
Bonn loss/decreased bone density
Decreased muscle mass/strength
Hard to build maintain muscle
decreased exercise tolerance longer recovery time
Are you able to have erections
Do you have morning erectins
Are you able to have an orgasm regulary
Durring sex are you able to maintain an erection

Additional comments

Goals of Care

Please Upload Lab work *

Browse Files

Please upload drivers license*

Browse Files

By using this service, I authorize Live Well Rx, its pharmacy and medical associates or any of its agents to receive my information via telehealth and supply medications from a pharmacy, and post it to me. I agree to waive my right to a pharmacist consultation (except for medications that require pharmacological guidance), and am aware that I can consult a pharmacist via e-mail or telephone. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it. I hereby authorize use or disclosure of protected health information about me. I consent to treatment as proposed by my clinical provider. I further acknowledge that I understand the risks and benefits of this treatment and agree to receiving treatment. I have complete understanding of and agree to follow the terms of this Informed Consent. A copy of this document has been given to me

I agree

Live Well RX is only a concierge technology platform and is not an internet pharmacy or a licensed medical clinic and does not prescribe, consult, dispense, ship, or distribute medications from our facility or website. Any and all medication are prescribed by our partner doctors and/or associated medical staff and will be dispensed from a FDA-approved pharmacy. All patients are required to fulfill and follow all of the medical instructions and procedures prescribed by doctors and contact their prescribing doctor immediately if they have any problems. Patients who are found to have submitted fraudulent information will be terminated from any health program offered by Live Well RX. Any medication prescribed is only for the use of the patient and is not to be transferred, distributed, modified, or used by any other person(s). You agree to hold Live well RX and its associates harmless. Live Well RX complies with HIPAA and wants to exchange text messages with you. By agreeing and clicking the Submit below, you agree to receive text messages from Live well RX and its doctors/providers. These text messages may contain details about your care providers, programs, healthcare reminders, or conditions. You acknowledge and agree that text messages are never completely private or secure. You understand text messages will be sent unencrypted and may be read or intercepted by others.

I agree

Telehealth Mens Health/HRT Intake

Patient Information

Medical Data

Assessment