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
Florida
Idaho
Maine
Montana
Nebraska
Nevada
New Mexico
New York
Ohio
Oregon
Texas
Utah
Virginia
Washington
6
What is your date of birth?* This field is required.
Date
Month
Day
Year
7
Which service are you interested in?* This field is required.
Online TRT
Peptides
ED Meds
Complete Male Optimization
Several
Help me decide
8
Are you new to TRT or Transferring Care?* This field is required.
New to TRT (never been on treatment)
Transferring from another provider (Seen in the past 6 months)
9
What is your current weekly prescribed dosage of Testosterone?* This field is required.
50-160mg/week
170-250mg/week
Over 250mg/wek
10
Are you interested in HCG to maintain testicular size and fertility?** This field is required.
Yes - HCG is important to me
No - Not needed
I'd like to discuss this with the provider
11
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
Row 2, Column 1
No, but I am interested.
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Yes
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No
Row 3, Column 1
No, but I am interested.
Row 3, Column 2
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12
Have you completed labs in the past 60 days?* This field is required.
Yes - I have recent labs
No - I need labs ordered
Im not sure
13
Which level of care best fits your needs?* This field is required.We offer three levels of care based on what matters to you. Each program includes Testosterone Cypionate up to 160mg/week, labs, provider visit, supplies, and shipping. The main difference is the labs we check, the time with the provider each month, and discounted access to peptides, ED, and longevity medication.
QUICK TRANSFER - $199 for 3 months -Basic labs and 20 minute provider visit included every 3 months)
STANDARD CARE - $119/month - Standard labs, 30 minute provider visit each month
COMPREHENSIVE CARE - $399/month - Complex labs (including vitamin and mineral deficiency), unlimited provider visits, 1 hour lab review and custom plan building, significant discounts on all products including peptides, longevity medication, supplements, and ED medication.
Im' not sure. I would like to talk to someone to better understand.
14
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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