Men's Health Colorado Onboarding

1
Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Please enter a valid phone number.
3
I agree to receive SMS messages from Cost Plus TRT* This field is required.By providing your phone number, you agree to receive SMS messages from Cost Plus TRT regarding appointments, follow-ups, and promotional offers. Message & data rates may apply. Message frequency varies. Reply STOP to opt out or HELP for help. Your information will not be sold or shared with third parties.”
4
Email* This field is required.
example@example.com
5
Which state do you live in?* This field is required.
Please Select
Please Select
Arizona
Colorado
Maine
Montana
Nebraska
New Mexico
Oregon
Utah
Washington
6
Select how you would like to start with Cost Plus TRT.
All-Inclusive Online TRT
Order labs and meet with Provider
Free TRT program Q&A
7
Have you previously been diagnosed with low testosterone (via blood test)?* This field is required.If you are transferring care to us, we can use your latest labs.
YESNO
8
Are you currently on TRT?* This field is required.
YESNO
9
Do you have recent labs?* This field is required.If you are transferring care to us, we can use your latest labs.
YESNO
10
When were your labs done? (MM/YYYY)* This field is required.If you have a general idea, but don't know the exact timeline, take a guess.
11
Have you ever been diagnosed with Prostate Cancer?* This field is required.If you are transferring care to us, we can use your latest labs.
YESNO
12
Certification on Truth* This field is required.I confirm that all answers I have given are true to my knowledge and will not hold responsible provider or provider group for issues pertained to TRT due to withholding information above.
Clear
13
Payment & Cancellation Agreement* This field is required.By booking an appointment, I understand and agree to the following terms: Payment Authorization: I authorize Cost Plus TRT to charge my card for the cost of my appointment at the time of booking. Cancellation Policy: I understand that a minimum of 24 hours’ notice is required to cancel or reschedule my appointment without penalty. Late Cancellation / No-Show Fee: If I cancel with less than 24 hours’ notice, arrive late, or fail to attend my appointment, I agree to be charged a $50 late cancellation or no-show fee to the card on file. Acknowledgment: I understand that these fees are necessary to reserve provider time and ensure efficient patient scheduling.
Clear
14
My Products
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Great Product Name
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Size:Small
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$20
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Size:Small
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ORDER SUMMARY
Total costUSD
Local Labs and Online VisitLab orders are sent to you for a local LabCorp. Once completed, we will send you a scheduling link to book a 20-30 minute visit with a TRT provider to review the results, answer your medical questions, and provide a plan to reach your goals.
$149.00Edit
Back
At-Home Labs and Online VisitReceive a home TRT testing kit in the mail. Perform the testing and mail it back in a pre-paid package. Once we have the results, we will schedule you to be seen by a provider to review the results, answer questions, and review a plan to reach your goals.
$199.00Edit
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Total cost $0.00
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