First Name

Last Name

City

State
AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip

E-mail

Best Contact Phone

Best Way To Contact You
Email Home Work Cell

Age
Please select your age 30 or less 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100

Gender
Male Female

Height
Feet 3' 4' 5' 6' 7' Inches 1" 2" 3" 4" 5" 6" 7" 8" 9" 10" 11"

Weight

Fitness Level
Excellent Good Fair Poor

Have you noticed: (check all that apply)
Decreased sex drive
Decreased energy levels
Loss of strength
Loss of endurance
Sexual performance issues
Work performance issues
Decreased quality of life
Changes in body composition
Increased recovery time
Decreased mental acuity

Do you have any major medical issues?
Yes No

If yes, please explain:

Have you ever benefited from HRT?
Yes No

Do you know someone else who has benefited from HRT?
Yes No

Are you self employed?
Yes No

What is your occupation?

Would you be willing to travel to one of our affiliate physicians for the initial appointment?
Yes No

How much of a monthly investment are you able to budget to improve your quality of life?
$250-$350/month $351-$600/month $601-$900/month Over $900/month

Additional Comments

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