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
Which service are you interested in?* This field is required.
Online TRT
Peptides
ED Meds
True Complete Optimization
7
Are you currently on TRT?* This field is required.
YESNO
8
What is your current weekly prescribed dosage of Testosterone?* This field is required.
50-160mg/week
170-250mg/week
Over 250mg/wek
9
Are you currently prescribed any of the following?
Yes
No
No, but I am interested
Estrogen blockers
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HCG
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ED Medication
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Peptides
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Estrogen blockers
HCG
ED Medication
Peptides
Yes
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No
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No, but I am interested
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Yes
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No
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No, but I am interested
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Yes
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No
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No, but I am interested
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Yes
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No
Row 3, Column 1
No, but I am interested
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Image Field
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Select how you would like to start with Cost Plus TRT.* This field is required.
All-Inclusive Online TRT
Order labs and meet with Provider
Free TRT program Q&A
12
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
13
Do you have recent labs?* This field is required.If you are transferring care to us, we can use your latest labs.
YESNO
14
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.
15
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
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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.
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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.
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