Bolt.Health Enrollment

New Patient Enrollment
We have successfully received your payment. Complete your enrollment by answering the following medical history questions.
Basic Information
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In your own words please describe what you are experiencing and/or are concerned about that lead you to consider testosterone therapy.

Lower Urinary Tract Symptoms (LUTS)

Please select an answer for each question below.*

	Yes	No
Do you have trouble starting urination, a weak urine stream, or feel that your bladder doesn’t empty completely?
Have you been diagnosed with an enlarged prostate (benign prostatic hyperplasia/BPH)?
If yes, are your urinary symptoms currently untreated or poorly managed?

Male Breast Cancer
Have you ever been diagnosed with breast cancer?

YesNo

Obstructive Sleep Apnea (OSA)
Do you snore loudly, stop breathing during sleep and/or wake up feeling very tired?*

YesNo
Have you been diagnosed with obstructive sleep apnea?*

YesNo
If yes, are you using a treatment for your sleep apnea, such as a CPAP machine and is your sleep apnea well controlled?

YesNo

High Red Blood Cell Count
Have you ever been told you have a high red blood cell count, polycythemia, or thick blood?*

YesNo
Have you had blood clots or other blood-related issues?*

YesNo

Liver and Kidney Function
Have you ever been diagnosed with any liver disease, such as Hepatitis (A, B, or C), Cirrhosis / scarring of the liver or Fatty liver disease?

YesNo
Have you ever been diagnosed with kidney disease or kidney failure?

YesNo

Tobacco Use
Do you smoke tobacco?*

YesNo
If yes, how many cigarettes do you smoke per day?

Alcohol Use
Do you drink alcohol?*

YesNo
If yes, how many drinks per week?

Recreational Drug Use
Do you use recreational drugs?*

YesNo
If yes, please describe which drugs you use and how often.

Exercise, Weight, Height, Diet and Sleep
How often do you exercise?*
What is your most recent body weight in pounds?*
What is your height?*
What is your diet?*
How many hours per night do you sleep, on average?*
How is the quality of your sleep?*

Surgeries
Please describe any surgeries you've had.

Medications
What medications are you currently taking?
Prescription and over the counter.
Please list any medication allergies.

Last one...
Any other specific questions you would like to discuss with the medical provider?

Consent
CONSENT TO TREATMENT AND PRIVACY POLICY OVERVIEW

This document outlines your consent to participate in Bolt.Health’s testosterone therapy program. It also describes how your health information may be used and disclosed, as well as your rights regarding access to this information. By signing, you agree to the terms stated below.

Understanding Testosterone Replacement Therapy (TRT)

Medicine is not an exact science, and treatment outcomes can vary. While TRT is designed to optimize testosterone levels and alleviate symptoms, individual results are not guaranteed.

Your clinical provider will explain the potential benefits, risks, and alternatives to TRT, including the option of no treatment. It is your responsibility to ask any questions before proceeding with therapy.

Potential Risks and Side Effects

TRT restores testosterone to physiological levels to relieve symptoms and improve quality of life. However, as with all medical treatments, side effects can occur, including but not limited to:

Common and Temporary Side Effects:
- Overproduction of red blood cells
- Decreased natural testosterone and sperm production
- Breast tenderness or swelling
- Acne
- Aggressiveness
- Increased body hair
- Sleep disturbances, including sleep apnea
- Mood changes, including irritability or aggressiveness
- Increased estrogen levels
- Water retention
Possible Health Impacts:
- Changes in cholesterol, PSA levels, liver, and kidney function
- Blood clots, stroke, sleep apnea or tendon rupture (rare)
Prostate and Cardiovascular Health:
- TRT does not cause prostate cancer but may accelerate pre-existing prostate conditions.
- The effect of TRT on heart disease is inconclusive, with some studies suggesting a reduced risk and others suggesting an increased risk.
- TRT should only be used under careful medical supervision, with regular monitoring of heart and prostate health.
Your Responsibilities:
- You must comply with recommended dosing and periodic lab tests for safe monitoring.
- It is your responsibility to discuss prostate cancer screening with your primary care physician or urologist.
- If any new or concerning symptoms arise, you must inform your provider immediately.
Acknowledgment of Risk and Consent to Treatment

I understand and agree to the following:
- No Guarantees: I acknowledge that TRT may not produce the desired results.
- Shared Responsibility: I will provide accurate medical history and report any health changes.
- Exclusion Criteria: I confirm that I do not have conditions such as active cancer or severe cardiovascular disease, which may disqualify me from treatment.
- Prostate and Cardiac Monitoring: I understand that while TRT does not cause prostate cancer, I am responsible for prostate screening. I acknowledge that TRT’s cardiovascular effects are still under study.
- Possible Adverse Effects: I understand the potential side effects and will adhere to my provider’s monitoring recommendations.
USE AND DISCLOSURE OF HEALTH INFORMATION

Bolt.Health complies with applicable privacy laws to protect your health information. Your records may be used for:
- Treatment: Evaluating and managing care, including consultations, lab tests, and prescriptions.
- Operations: Service fulfillment, staff training, quality improvement, compliance with legal and administrative obligations.
Your information will not be shared with third parties except in the following cases:
- As required by law (e.g., court orders, regulatory requirements).
- For public health and safety purposes (e.g., reporting communicable diseases, medical emergencies).
- To report abuse, neglect, or threats to safety.
You have the right to:
- Request restrictions on how your information is shared (subject to approval).
- Choose confidential communication methods.
- Access your records and request a copy of this Notice.
PAYMENT AND REFUND POLICY

Bolt.Health is a cash-pay service and does not accept insurance reimbursement. Patients may submit receipts for HSA or personal insurance claims.

Refund Policy
- Refunds for the initial lab test are only provided if disqualification occurs before therapy initiation.
- If the lab test is invalid due to processing errors, a retest or refund will be offered.
- No refunds will be issued once treatment has begun.
RELEASE OF LIABILITY AND INDEMNIFICATION

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

Acknowledgment of Risk

All medical treatments, including TRT, carry inherent risks. These risks may include but are not limited to changes in hormone levels, cardiovascular effects, prostate complications, and mood fluctuations.

While Bolt.Health provides medical guidance, I am ultimately responsible for my health and treatment decisions.

Assumption of Responsibility

I accept full responsibility for any risks, injuries, or adverse outcomes associated with TRT, provided that Bolt.Health and its providers meet professional medical standards of care.

Indemnification

I agree to indemnify, defend, and hold harmless Bolt.Health, its affiliates, staff, contractors, and providers except in cases of gross negligence, fraud, or willful misconduct. This includes claims arising from:
- My participation in TRT
- My reliance on Bolt.Health’s recommendations
- Any misrepresentation or omission of my medical history
Release of Liability

I release Bolt.Health and its providers from liability for treatment outcomes, except in cases of gross negligence or medical malpractice.

ARBITRATION AGREEMENT

Agreement to Arbitrate

Any dispute, claim, or controversy arising out of or relating to this agreement, including disputes related to medical treatment, services, fees, or any alleged breach of contract, negligence, or other claim, shall be resolved exclusively through binding arbitration in accordance with the rules of the American Arbitration Association (AAA).

Waiver of Jury Trial

By agreeing to arbitration, both parties waive their right to a jury trial or participation in a class-action lawsuit. Arbitration shall be the sole means of resolving disputes.

Governing Law and Arbitration Venue

This arbitration agreement shall be governed by the laws of the state of Colorado. Arbitration proceedings shall take place in Colorado unless both parties agree to another location.

Costs and Attorney’s Fees

Each party shall bear their own costs and attorney’s fees unless the arbitrator determines otherwise.

Exceptions to Arbitration

This arbitration agreement does not apply to:
1. Claims related to gross negligence, fraud, or willful misconduct by Bolt.Health.
2. Claims that are legally required to be resolved in a court of law or administrative agency.
Severability

If any part of this arbitration clause is found unenforceable, the remaining provisions shall still apply.

GOVERNING LAW

This agreement is governed by the laws of Colorado without regard to conflict-of-law principles.

LAST UPDATED

This agreement was last updated on March 26, 2025. Future revisions may be made to reflect changes in policies, regulations, or services.
Acknowledgment and Agreement

By signing below, I confirm that I understand the terms, conditions, risks and responsibilities outlined in this agreement. I acknowledge that I have had the opportunity to ask questions and seek independent legal counsel before signing this agreement.
Patient Full Name*

First NameLast Name
Patient Date of Birth*

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Patient Signature*

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Date Signed*

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Should be Empty:

	Severe Symptoms	Moderate Symptoms	Mild Symptoms	Minimal Symptoms	No Symptoms
Decrease in libido (sex drive)
Lack of energy
Decrease in strength and/or endurance
Lost height
Decreased "enjoyment of life"
Sad and/or grumpy
Erections less strong
Recent deterioration in your ability to play sports
Falling asleep after dinner
Recent deterioration in your work performance

	Yes	No	Unsure
Have you ever been diagnosed with prostate cancer?
Have you had abnormal results from a prostate-specific antigen (PSA) blood test?
Has a primary relative (father, brother, son) ever been diagnosed with an aggressive form of prostate cancer?
Have you had any abnormal or unusual prostate exam results?

	Yes	No	Unsure
Have you ever been diagnosed with congestive heart failure (CHF)?
Have you ever been diagnosed with a Heart attack (myocardial infarction), Coronary artery disease or blocked arteries?
If yes to either of the above, is your heart condition currently well-controlled with treatment? If not applicable, select no.
Have you ever been diagnosed with a stroke or TIA (transient ischemic attack)?

	Yes	No
Are you currently planning to have children in the near future?
Have you been diagnosed with any conditions affecting fertility or are you concerned about your ability to have children?
Are you currently on testosterone therapy?
Have you ever experienced infertility issues?
Are you interested in sperm banking/ sperm preservation?

New Patient Enrollment

Basic Information

Medical Questionnaire

Prostate Cancer

Lower Urinary Tract Symptoms (LUTS)

Male Breast Cancer

Cardiovascular Health

Obstructive Sleep Apnea (OSA)

High Red Blood Cell Count

Fertility

Liver and Kidney Function

YOUR Medical History

FAMILY Medical History

Tobacco Use

Alcohol Use

Recreational Drug Use

Exercise, Weight, Height, Diet and Sleep

Surgeries

Medications

Last one...

Consent

Acknowledgment and Agreement