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
9
My Products* This field is required.
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Lab Order and Online Provider VisitLocal lab order sent to you for LabCorp. Once labs are back, we will text you to schedule your first visit.
$149.00Edit
Back
At-Home Labs and Online Provider VisitMail-order TRT labs shipped to your door. Complete the labs and send them back in a pre-paid container. We will text to schedule your online provider visit once the lab results are available.
$199.00Edit
Back
Total cost $0.00
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