Hormone Therapy & Weight Loss Treatment Intake Form

Testosterone Replacement Therapy (TRT) Intake Form

Please fill out this form accurately to help us understand your health background and tailor our treatment options accordingly.
Patient Name & Information

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender
Date of Birth

MonthDayYear
Date
Referred By
Treatment Interest
Do you have health insurance?
Have you recently discontinued Testosterone Replacement Therapy (TRT)? If yes, what form (injections, gels, pellets, etc.) and dose?
Did you stop TRT? Why?
Medical History
Please Select All That May Apply
Do you have any of the following allergies?
Please list any current medication.
Insurance Provider (if applicable)
Current Medications
Pre-existing Medical Conditions
Allergies or Adverse Reactions
Lifestyle Factors (e.g., alcohol, tobacco, drug use)
Do you have a history of hormone-related conditions?
Do you use tobacco products?
Do you consume alcohol regularly?
Symptoms Checklist
Please Select All That May Apply
Acknowledgements
I understand and agree that:

I understand that enrollment in the American Hormone Institute program provides me access to licensed medical providers who specialize in hormone and wellness care. My individualized treatment plan will be based on my medical history, lab results, and direct consultation with a licensed provider. All medical decisions, including the initiation, modification, or discontinuation of hormone therapy, will be made solely by a licensed provider, independent of AHI’s administrative services.I further acknowledge that hormone therapy carries certain risks and requires ongoing monitoring. I agree to complete bloodwork, participate in periodic follow-ups, and inform my provider of any changes in my health status or medications. I understand that treatment outcomes may vary and that there is no guarantee of results.
I consent to the following:

To share my medical information with American Hormone Institute’s medical team and its authorized pharmacy/lab partners solely for the purpose of evaluation, treatment, and medication fulfillment. I authorize the use of HIPAA-compliant telehealth tools for consultation, follow-up, and prescription management. I acknowledge this is a subscription-based service and understand the billing structure as outlined in my selected plan. I have read and understood the risks and benefits of treatment, and I voluntarily consent to begin TRT under medical supervision.
Digital Signature for Consent
Bloodwork

Bloodwork is required for our physician to review. This is to protect you. If you have bloodwork within the last 90 days, you can upload your results below. If you do not have bloodwork, We can set you up at a Quest Diagnostic or LabCorp near you.
Please upload any bloodwork within the last 90 days

Cancelof
Should be Empty:

Testosterone Replacement Therapy (TRT) Intake Form

Medical History

Symptoms Checklist

Acknowledgements

Bloodwork