Clone of TRT/Peptide/Weight Loss 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
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
7
Are you currently on TRT?* This field is required.
YESNO
8
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
Should be Empty: