TRT Reorder Check In Form
Name
First Name
Last Name
Date of Check In?
Email
example@example.com
Since your last order, how are you feeling? (scale 1–5)
1
2
3
4
5
Are you currently taking your TRT as prescribed?
Yes
Mostly (missed doses)
No (please explain)
If no please explain why.
Please check the following improving symptoms:
Energy Levels
Libido / Sexual Function
Mood / Motivation
Sleep Quality
Body Composition / Strength
Other
Additional notes or changes you've noticed:
Have you experienced any of the following? (Check all that apply)
Acne
Water retention / bloating
Mood changes / irritability
Low libido
Breast tenderness
Fatigue
Difficulty sleeping
Other
New Supplements or Medications?
Have you had a TRT Review Panel in the last Six Months?
Yes
Not yet
I would like a panel sent to my email
Please upload any new lab work.
Browse Files
Drag and drop files here
Choose a file
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Would you like information on peptide options during this cycle?
Yes — I’m interested
Maybe — depends on recommendation
No — not at this time
What are your TOP Goals with additional peptide therapy? (Select all that apply)
Fat loss
Muscle recovery
Libido
Sleep
Joint pain
Anti-aging
Energy & focus
Would you like a nurse consultation before your next order?
Yes — I’d like a nurse check-in
Not needed at this time
Additonal Questions For Liaison/Dr. Rucker
I understand this check-in is required prior to medication refills and that my responses help guide safe and effective care.
Yes
No
I approve Dr. Rucker to reorder my next package
Yes
No
Phone Number
*
In case a Reverse Nurse to connect with you
Format: (000) 000-0000.
Submit & View Lab Orders
Should be Empty: