Dr. Jatoi Hormone Replacement Therapy Medical Intake Form

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Steps To Proceed* This field is required.1) Fill out the intake form. If approved, proceed to payment. 2) Take your emailed lab order to your local lab drawing facility, typically covered by insurance. Doctors get results within 3-5 business days. 3) Consult will be scheduled with labs being resulted and options for proceeding with medical treatment. *If you are not a candidate, alternative options will be presented, otherwise, we will refund your paid fees back to you.
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Patient Name* This field is required.
First Name
Last Name
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Patient Information* This field is required.
Date of Birth
Cell Phone Number
Please enter your email
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Female
Sex at Birth
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Patient Address* This field is required.
Street Address
Street Address Line 2
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Personal Medical History
Heart Disease
Stroke
Blood clots (DVT / PE)
BPH
Prostate Cancer History
Hypertension
Liver Disease
Kidney Disease
Depression
Anxiety
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Have you ever been on testosterone treatment?* This field is required.
YESNO
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When were you on TRT last, what dose were you on, how often did you administer it? Any other pertinent details to your TRT treatment.
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Testosterone Symptom Tracker
Burnt out / motivation loss
Feeling depression
Decreased libido
Decrease physical stamina
Erection/Potency Problems
Loss of morning erection
Decreased muscle mass
Sleep disturbances
Increase in waist size
Acne
Insomnia
Mood swings
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Excess Estrogen Tracker
Insomnia
Hot flashes
Mood swings
Weight gain in mid section
Breast tenderness / Fullness
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Are you still planning on having children?Patients on testosterone will have a decrease in sperm counts, if you are trying to have children you should not be on Testosterone replacement.
YESNO
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Comments / Concerns / Questions (optional)Any additional comments, concerns, questions that you may have for Dr. Jatoi that is pertinent to medical weight loss journey in the past or now? Feel free to attach any pertinent attachments, labs, records you feel is appropriate. Labs are not necessary to start on GLP-1 treatment, but may will be required if you want metformin to augment weight loss with GLP-1 injectables.
Huge
Large
Normal
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Ok
Ok
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Physician Fees - Hormone Replacement Therapy Concierge Fees* This field is required.This fee provides direct access to Dr. Mansoor Jatoi for advice on dose adjustments, questions about medications, side effects, and dose changes. It is required for receiving medications via Dr. Jatoi. New Patient HRT Concierge/Doctor Fees: $120 (monthly) or $200 (bi-monthly) Discount can be applied if already on Dr. Jatoi's medical weight loss program ($95 monthly) This will automatically renew on your credit card until canceled. If you cancel or let your concierge membership lapse and wish to re-enroll, there is a $50 re-enrollment fee. Cost of medication is included, cost of labs are not and typically can be billed to your medical insurance or we can help you find cheaper cash paying alternatives.
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Informed Consent of TRT* This field is required.Purpose of Testosterone Therapy: Testosterone Replacement Therapy (TRT) is used to treat low testosterone (hypogonadism), which can cause symptoms like fatigue, low libido, muscle loss, and mood changes. The goal is to restore normal testosterone levels and alleviate these symptoms. Benefits of TRT: Improved energy, mood, and libido Increased muscle mass and strength Better cognitive function Reduced body fat Increased bone density Risks and Side Effects Common Side Effects: Acne or oily skin Fluid retention Breast tenderness or enlargement Increased red blood cell count Serious Risks: Increased risk of heart attack, stroke, or blood clots Worsening of prostate conditions (e.g., BPH, prostate cancer) Alternatives to TRT: Lifestyle changes (diet, exercise) Other medications (e.g., clomiphene, hCG) Patient Acknowledgment: I have read and understood the potential benefits, risks, and alternatives of TRT. I consent to treatment and agree to follow the care plan provided.
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Signature of Consent and AgreementBy providing your mobile number, you consent to receive text messages from Dr. Jatoi Direct Primary Care to discuss your healthcare-related information, test results, and appointments. Text messages may include sensitive health information. Standard messaging rates may apply. If you decide to sign up, you agree to a medical HRT concierge membership that automatically renews either every month or every two months depending on choice you prefer. By signing below you are agreeing to start the medical HRT program, if accepted, and ready for consultation and payment. If you do not wish to start, please close out of this window. Email questions you may have to Dr. Jatoi - mjatoi@drjatoidirectprimarycare.com
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