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Medical Forms

Each of the forms below are required for treatment with Hormone Therapeutics. Please download, fill out and return each via fax to 1-888-467-1838 or scan and email them to forms@hormonetherapeutics.com.  The last item is a collection of all of the forms in one download.

Credit Card Form – Download Form

Fill out our credit card and payment policies form.

MEDICAL EXAMINATION FORMDownload Form

Take this one-page examination form to your physical exam with the local physician of your choosing. Please ensure they indicate that you exhibit one of the symptoms of Low T on this form or on their own exam form, which they may choose to use.

MEDICAL HISTORY QUESTIONNAIRE – Download Form

This form gives our medical personnel a better understanding of your overall health and medical history. This will allow for a more complete health picture for our team to provide a more tailored approach to you.

PRIVACY PRACTICES AGREEMENT – Download Form

We must have all patients sign the Reception Form to indicate that we have made our privacy policies available for your review.

CONSENT FOR TESTOSTERONE AND HORMONE REPLACEMENT THERAPY – Download Form

This consent form is your agreement to undergo testosterone replacement therapy, and must be completed prior to therapy being administered.

AGREEMENT NOT TO USE OTHER TESTOSTERONE SUPPLEMENTATION – Download Form

This form is your agreement not to combine other testosterone supplementation with our treatment plan.

All DocumentsDownload Forms

Download and print all six documents.

*Right click the “Download Form” link and choose Save As if the forms are not displaying correctly for you.

Please download, fill out and return each via fax to 1-888-467-1838 or scan and email them to forms@hormonetherapeutics.com.

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