Allure TRT Questionnaire

1

What is your name?* This field is required.Please be accurate for patient records

First Name

Last Name

2

What is your email?* This field is required.This is important for appointment updates!

example@example.com

3

Phone Number* This field is required.Please make sure this is correct as we will be sending text reminders for your visits.

4

1. Do you have cancer currently?* This field is required.REQUIRED

YESNO

5

2. Do you have a family history of cancer?

YESNO

6

3. Are you over the age of 25?* This field is required.REQUIRED

YESNO

7

4. Do you have cardiomyopathy or any diagnosis of congestive heart failure?* This field is required.REQUIRED

YESNO

8

5. Have you ever taken testosterone or testosterone derivatives in the past?* This field is required.REQUIRED

YESNO

12

9. We do not accept insurance, are you okay with paying out of pocket?* This field is required.

YESNO

13

Now lets get you booked!

When booking, please select the

TELEHEALTH Option: Allure Medical Tele-Health Consultations MI

14

Thank you for completing the questionnaire. Unfortunately, based on your responses, you do not qualify for TRT at this time. If you have any questions, call 1 (866) 614-9605. If you made a mistake, please click the button below and begin the form again. Thank you!

I made a mistake, take me back!

I will try again when my situation changes.