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To get started, please fill out the intake form below.
1
Contact Information
2
Screening Questions
Contact Information
First Name
Last Name
Phone Number
Email
Date of Birth
Social Security Number
Height (in inches)
Weight (in lbs)
Address Line 1
Address Line 2 (Optional)
City
State
Zip Code
Driver's License Number
Driver's License State
I acknowledge that based on my age and/or state selection, I only qualify for Enclomiphene.
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Screening Questions
Cancer and Health Conditions
Current, or suspected prostate cancer
Breast cancer
Other cancer (active diagnosis, treatment, or remission less than 5 years)
Untreated/severe heart failure or heart disease
Uncontrolled blood pressure (systolic ≥ 160 or diastolic ≥ 100)
High blood counts (hemoglobin greater than 18 g/dL, hematocrit greater than 50%)
Untreated/severe sleep apnea
Desire to preserve fertility or have more children
Known hypersensitivity to testosterone, anastrozole, or enclomiphene
None of the above
What would you like to improve? (One or more must be selected)
Decreased sexual vigor and libido
Decreased energy or increased fatigue
Depressed mood or depression
Decreased muscle mass
Decreased body hair
Erectile dysfunction
Hot flashes
Low bone density
Poor sleep
Difficulty with focus/concentration
Weight gain
Joint pain
None of the above
Conditions Requiring Specialist Clearance or Caution
Past Prostate Cancer
Liver Disease
Brain or Pituitary Tumor
Uncontrolled adrenal disease
Uncontrolled thyroid disease
High Blood Pressure (systolic 140-159, diastolic 90-99)
Kidney disease
Elevated cholesterol levels
Controlled and treated heart failure
Controlled and treated sleep apnea
History of a blood clot
Testicular cancer
Estrogen-dependent tumor
Early puberty
Gynecomastia (benign breast tissue growth)
Shrinking testicles or small testes
Symptoms of enlarged prostate
None of the above
Testosterone History and Current Use
Low levels of testosterone on prior labs
Current or prior diagnosis of hypogonadism
Prior use of testosterone replacement therapy
Current use of testosterone replacement therapy
None of the above
Previous or Current Forms of Testosterone Replacement Therapy
Gel
Cream
Injection
Pellet
Pill
hCG (human chorionic gonadotropin)
Enclomiphene
Over the counter testosterone booster
None of the above
Details of Last Testosterone Dose
Current Medications
Allergies
Medication Type Preference
No Preference
Testosterone Cypionate Solution (Injection)
Testosterone Oral Dissolvable Tablet
Enclomiphene Oral Tablet
Coupon Code (If Applicable)
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