TRT (Testosterone Replacement Therapy) Scheduling Form

TRT (Testosterone Replacement Therapy) Scheduling Form
Welcome to East Coast IV, Your TRT Adventure Starts Here!

Hey there, we’re thrilled you’re joining the East Coast IV family to kick low energy, sluggish vibes, and that “meh” feeling to the curb with Testosterone Replacement Therapy (TRT). Whether you’re here to boost your mojo, build some muscle, or just feel like you again, we’ve got your back every step of the way. Here’s the quick scoop on what to expect as you schedule with us—let’s get you pumped (pun intended)!

The Rundown: How It Works

First, let’s start by completing this form. It’ll ask you all the pertinent medical history questions, have you sign our waivers, and give you the ins and outs of our TRT program here at East Coast IV. The cost for our TRT consultation is $99, which by the way includes your initial blood work order and review!

Once we you have submitted your request, we will pair you with one of our amazing licensed practioners for a consultation to ensure TRT is right for you and medically necessary.

Game Plan: Once you’re in, TRT injections cost $175/month, billed every 3 months ($525 total). You’ll also need comprehensive blood work panel 5 weeks after starting and again every 6-12 months to keep things dialed in. Got recent labs? Bring ‘em—we might be able to use them!

Your Role: TRT injections mean you’ll be your own VIP injector at home (don’t worry, we’ll teach you the ropes if you need it). Meds ship straight to you, and someone 18+ just needs to sign for them.

Ready to Start?

Picture this: more energy to crush your day, a libido that’s back in the game, stronger muscles, and bones that stay solid. It’s not instant magic—results take a few weeks—but stick with it, and you’ll feel the difference.

Book your consult now, and let’s unleash the best version of you. Questions? Hit us up—we’re here to make this smooth, simple, and maybe even a little fun. Welcome aboard, champ!
Patients Name:*

First NameLast Name
Date of birth:*

MonthDayYear
Date
Age:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Home Address: *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about our TRT program?*

Family or friendSocial MediaIn person eventGoogleOther
Who referred you? (first and last name) Lets make sure they get their $100 credit!
Current Symptoms*

AcneErectile Dysfunction (ED)Decreased LibidoDecreased DesireInability To or Delayed OrgasmWeight GainDecreased Muscle MassDifficulty SleepingUrinary IncontinenceDry or Flaking SkinLack of Energy (Fatigue)Decrease in Strength or EnduranceDecrease in Work PerformanceFrequent Urinary Tract InfectionBrittle NailsThinning EyebrowsHair ThinningCold Hands or FeetMind Racing at BedtimeMood SwingsGynecomastiaAbdominal ObesityNone of the above
Are you currently prescribed TRT through another provider?*

NoYes
Medical History
Cancer History*

Breast CancerActive Prostate Cancer or History of Prostate CancerThyroid Cancer or History of Thyroid CancerMeningiomaPolycythemia Vera (PV)Except for Basal Cell Carcinoma any Other Cancers?None of the above
Cardiovascular History*

Heart Attack or Stroke (within last 6 months)DVT or Blood Clot (within last 6 months)HypertensionHyperlipidemiaObstructive Sleep ApneaPatient Takes Anticoagulant MedicationAtrial FibrillationTachycardiaNone of the above
Fertility - Are you planning to have children in the next 12 months?*

YesNo
Neurological Conditions*

Epilepsy or Seizure DisorderDepression/AnxietyNone of the above
Endocrine and Metabolic*

Diabetes Type 2 or Insulin ResistanceHyperthyroidHypothyroidMultiple Endocrine Neoplasia Type-2None of the above
Autoimmune Conditions*

Diabetes Type 1Hashimoto’s ThyroiditisGraves’ DiseaseRheumatoid ArthritisMultiple SclerosisSystemic Lupus (Erthematosus)PsoriasisPositive ANAIBS (Irritable Bowel Syndrome)Crohn’s DiseaseUlcerative ColitisNone of the above
Organ Specific Conditions*

Liver Disease or History of Liver DiseaseKidney Disease or History of Kidney DiseaseLAM (Lymphangioleimyomatosis)Osteoporosis or OsteopeniaProstate Enlargement (BPH)HIVHepatistisHemochromatosisPancreatitis or History of PancreatitisHistory of or Gall Bladder DiseaseNone of the above
Are you currently taking any Rx or OTC medications?*

NoYes (Please list)
Lifestyle & Family History
Do you smoke or use tobacco products?*

NoYes (Which type and how long?)
Do you drink alcohol?*

NoYes (How often and how much?)
Do you exercise regularly?*

NoYes (How often?)
Does anyone in your immediate family (Parents, siblings) have a history of the following:*

Prostate CancerBreast CancerCardiovascular diseaseBlood Clotting DisordersLiver DiseasePolycythemiaSleep ApneaNone
Additional Info - Is there anything else about your health you’d like your provider to know?
East Coast IV Testosterone Replacement Therapy Waiver

This form outlines the risks, benefits, and responsibilities associated with Testosterone Replacement Therapy (TRT) providedby East Coast IV. By signing this document, you acknowledge that you have read, understood, and agreed to the terms outlinedbelow.

Informed Consent

I, the undersigned, acknowledge and agree to the following:

1. Purpose of Therapy

Testosterone Replacement Therapy aims to treat symptoms of low testosterone levels, which may include fatigue, reducedlibido, decreased muscle mass, mood changes, and other related conditions.

2. Risks of Treatment

I understand that TRT involves potential risks, which include but are not limited to:

• Acne or oily skin

• Increased risk of blood clots, stroke, or heart disease

• Enlargement of the prostate gland or increased risk of prostate cancer

• Sleep apnea

• Breast tissue enlargement or tenderness

• Mood swings or aggression

• Fertility impairment

I acknowledge that East Coast IV cannot guarantee the resolution of symptoms or specific outcomes from therapy.

3. Alternatives to Treatment

I understand that alternative treatments are available, including lifestyle modifications, other medications, or choosing notreatment at all.

4. Responsibilities and Compliance

• I agree to adhere to all therapy protocols as prescribed by East Coast IV’s medical providers.

• I will provide accurate medical history and disclose all medications or supplements I am currently taking.

• I understand the importance of regular follow-up appointments and laboratory tests to monitor the effects of therapy.

• I agree to notify East Coast IV immediately if I experience any adverse effects or changes in my health.

5. Billing and Financial Responsibility

• I understand that TRT is billed every three (3) months to the credit card on file.

• All sales of medications are final, as required by law.

• I may cancel therapy at any time by contacting East Coast IV. However, charges already processed will not berefunded.

6. Acknowledgment of Off-Label Use

I understand that some uses of testosterone therapy may be considered “off-label,” and I consent to receiving this therapy asdiscussed with my healthcare provider.

7. Release of Liability

I release East Coast IV, its employees, and contractors from any and all liabilities or claims arising from my participation in TRT,except in cases of negligence
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TRT (Testosterone Replacement Therapy) Scheduling Form

Medical History

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