Testosterone clinic

Testosterone Clinic

Evergreen Adult Medicine
Please note: If you are not a current family practice patient, and you only want to participate in the Testosterone Clinic, please only complete this form. Please do not complete the new patient packet.

For any patient wanting to participate in our testosterone clinic, family practice established or not complete this form and we we call you to set up.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
Email*

Confirmation Emailexample@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please List your Allergies: *
Please List Daily Medications, strengths, and directions:*

Insurance Information
Name of Insurance*
If no insurance please answer N/A
Subscriber ID on the card*
If no insurance please answer N/A
Subscriber Name *
If you are the subsriber, just type 'Self'. Otherwise put the name of the person that is the subscriber
Relation to subscriber*
If you are the subscriber, just type 'Self', Otherwise your relationship to the subscriber.
Date of Birth of subscriber*

MonthDayYear
Date

*This is for testosterone clinic only and our office will not be responsible for your chronic medications and testing. Please contact your family doctor if you need medications other than what we will be prescribing.

The first visit is $95 and each visit after is $75. This is due at the time of service. This fee does not include the medication. If we participate with your PPO insurance, we will submit the office visit to your insurance. Please bring your Driver's License and insurance card to the appointment. Please note, we do not accept any form of medical assistance.

We will ask about insurance information when we call you to schedule.

We do ask that you have some labs completed prior to your first appointment. Our staff will review this when we contact you to schedule your first appointment.

Thank you.
Please list all the symptoms that you are currently having (example fatigue, low libido, etc.) ?*
If no labs completed please put N/A as answer
Have you had a recent lab test including PSA or Total testosterone ?*
If no labs completed please put N/A as answer
If so date and place of service? *
If no labs completed please put N/A as answer
Signature of patient*
How did you hear about this program?*
Please verify that you are human*
Should be Empty:

Testosterone Clinic