• Male Testosterone Injection Intake, Consent & Provider Note

    Standard online medical intake, consent, and provider note form. Preserve the extracted PDF wording verbatim for all medical, risk, consent, and attestation text.

  • Patient Demographics & Contact

  • Date of Visit*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medications & Allergies

  • Allergy severity*

  • Family History

  • Family History of prostate cancer?*
  • Family history of early heart disease or heart attack?*
  • Family history of stroke?*
  • Family history of blood clot / DVT / PE?*
  • Family history of clotting disorder?*
  • Family history of polycythemia or elevated red blood cell disorder?*
  • Family history of sudden cardiac death?*

  • Prior Hormone/Steroid Use

  • Have you used testosterone before?*
  • Have you used anabolic steroids before?*
  • Check any symptoms you are currently experiencing*
  • Check any medical conditions you have (past or present)*

  • Contraindications

  • Prostate cancer*
  • Male breast cancer*
  • Elevated PSA*
  • Untreated severe sleep apnea*
  • Uncontrolled heart failure*
  • Recent heart attack or stroke*
  • High hematocrit / polycythemia*
  • Active blood clot*
  • Fertility goals / trying to conceive*
  • Allergy to testosterone or carrier oil*
  • Safety questions (check any symptoms you are currently experiencing)*

  • Patient Signature

  • Date Signed*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Provider Attestation

  • Date signed*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: