Enclo Telehealth Intake Form

Eligibility and Medical Screening
State of Residence
Were total testosterone, free testosterone, and estradiol lab work drawn in the last 6 months?
I am biologically male:
Patient Information
Full Name

First NameMiddle NameLast Name
Email Address
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Medical History
Medical diagnoses and medical problems; if none please write "none"
Current medications or substances being taken; if none please write "none"
Medication allergies; if none please write "none"
If you have any of the following lab values, please provide them along with the date the labs were drawn: Total Testosterone, Free Testosterone, Estrogen or Estradiol. Note, answering this question is not required but helps the Doctor in his evaluation.
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Eligibility and Medical Screening