REVERSE MED TRANSFER 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

Who is your current provider?* This field is required.

3

What is your current weekly dosage?* This field is required.

4

What are you currently paying per month or per refill?* This field is required.

5

Welcome To Reverse Medical

6

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

I am happy with my health just looking for a cheaper solution to maintain it

7

What are your top 1-2 primary goals right now? (Select up to 2)* This field is required.Select up to 2 primary goals

Fat loss

Energy optimization

Muscle & strength

Libido & performance

Mental clarity

Longevity / anti-aging

8

What symptoms are most frustrating right now? (Select all that apply)* This field is required.Select all that apply

Low energy

Brain fog

Stubborn body fat

Low motivation

Low libido

Poor sleep

Mood changes

9

Have you previously tried GLP-1 medications (like Semaglutide or Tirzepatide) alongside your TRT? If yes, how did you respond?Please describe your response if applicable

10

What do you struggle with most when it comes to weight? (Select all that apply)Select all that apply

Appetite control

Sugar or carb cravings

Slow metabolism

Emotional eating

Lack of energy to exercise

11

How many days per week do you currently resistance train?

0-1 days

2-3 days

4-5 days

6+ days

12

How satisfied were you with your results on your previous TRT protocol?* This field is required.

Very satisfied — just looking for a better price

Somewhat satisfied — wanted better results

Not satisfied — protocol was not working

Never felt a difference

13

Do you have trouble falling asleep, staying asleep, or both?

Trouble falling asleep

Trouble staying asleep

Both

14

Are you currently taking any medications for erectile dysfunction (e.g., Viagra, Cialis)?

Yes

No

15

Do you have any current joint pain, tendon issues, or injuries that limit your training?

Yes

No

16

What is your name?* This field is required.

First Name

Last Name

17

What is your current TRT Routine?(Medications and Dosages)

18

Were you referred to Reverse by someone?we’d love to know so we can thank them properly.

19

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

example@example.com

20

Why are you looking to switch providers?Please be specific and explain why you need Dr. Rucker’s help. Goals do not need to be physical goals.

21

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

22

TRT Transfer Program Structure (If Approved). All options include: 10mL Testosterone Cypionate vial, shipping included, injection supplies (syringes, needles, alcohol pads), Anastrozole prescribed if clinically indicated, physician oversight and lab review, and access to the Reverse Peptide Marketplace with member-level pricing. Choose your refill structure: $85 per month (membership billing), $150 every 8 weeks (10mL vial shipped every 8 weeks), $170 every 10 weeks (10mL vial shipped every 10 weeks). Transfer applications are reviewed weekly based on provider capacity.

Yesterday

Today

Not Ready Yet

Would like More Info First

23

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

24

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

I want my current plan delivered for $85/mo.

I want my current plan delivered for $150 every 8 weeks.

I want my current plan delivered for $170 every 10 weeks.

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

25

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

Peptides

ADHD

Erectile Dysfunction Treatment

Hair Loss Treatment

Other

26

Are you interested in Speaking with Dr. Rucker About A MED MMJ Card?FLORIDA PATIENTS ONLY

Yes

No

27

Do you have a personal history of prostate cancer or breast cancer?

Yes

No

Not Sure

28

Have you ever been diagnosed with severe sleep apnea, congestive heart failure, or a high red blood cell count (polycythemia)?

Yes

No

Not Sure

29

Are you currently trying to conceive or planning to have children in the near future?

Yes

No

30

Do you currently have an active cancer diagnosis or are you undergoing any form of cancer treatment?

Yes

No

31

Are you currently taking blood thinners, corticosteroids, or insulin?

Yes

No

Not Sure

32

Did your previous TRT provider ever flag any lab concerns (e.g., high hematocrit, elevated PSA, or estrogen issues)?

Yes

No

Not Sure

33

Please describe the lab concern and any treatment adjustments that were made.

34

Please provide additional details about your cancer history so our medical team can review before recommending any TRT protocol.

35

Please describe your condition and when you were diagnosed so our medical team can assess appropriately.

36

Important: Standard TRT can suppress natural testosterone production and reduce sperm count. Our team will discuss fertility-preserving options such as HCG or Enclomiphene with you during your consultation.

37

Do you have recent lab work from your current provider? (within the last 6 months)

Yes — I can upload them

Yes — but I do not have them on hand

No — my provider did not monitor my labs

38

Which labs were included in your most recent panel? (Select all that apply)

Total Testosterone

Free Testosterone

Estradiol (E2)

LH / FSH

Hematocrit / CBC

Comprehensive Metabolic Panel (CMP)

PSA (Prostate-Specific Antigen)

Thyroid Panel (TSH)

None of the above

39

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

40

If you would like New Labs, we can send you a lab script to your email. We offer a T Level Check at Quest for $10 (We Pay The Rest)

I want new Labs!

Want to speak to Dr. first

Not at this time

41

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.

42

REAL PATIENT 6 MONTH LAB REVIEW