TRT & Men's Hormone Therapy Intake

Step 1 of 6

Patient Information

Please complete all fields accurately. This information is used to coordinate your TRT and hormone optimization care.

Personal Details

First Name *

Last Name *

Date of Birth *

State *

Occupation

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

Step 2 of 6

Symptom Assessment

Rate each symptom over the past 4 weeks. 0 = None | 1–2 = Mild | 3–4 = Moderate | 5 = Severe

Energy, Drive & Sexual Function

Low energy / fatigue

Persistent tiredness that doesn't improve with rest

Low libido / sex drive

Reduced interest in sexual activity compared to prior baseline

Erectile dysfunction

Difficulty achieving or maintaining erections

Mood & Cognition

Depression / low mood

Persistent sadness, hopelessness, or emotional flatness

Brain fog / poor concentration

Difficulty focusing, word-finding, or mental sluggishness

Irritability / mood swings

Physical

Loss of muscle mass / strength

Increased body fat / belly fat

Poor sleep quality

How long have you had these symptoms?

Any other symptoms not listed above?

Prior TRT Experience

Have you been on TRT before?

Step 6 of 6

Informed Consent & Signature

Please read carefully. Your electronic signature has the same legal effect as a handwritten signature under the federal E-SIGN Act (15 U.S.C. § 7001) and applicable state electronic transactions laws.

Consent for TRT & Men's Hormone Therapy

Nature of Treatment

I am consenting to receive testosterone replacement therapy (TRT) and/or related hormone optimization prescribed by a clinician licensed and authorized to evaluate and prescribe for me in my state of residence through the outfitMD partner network. Testosterone may be administered via injection, topical gel/cream, pellet, or other physician-selected delivery method based on my clinical profile.

Potential Benefits

Improved energy, libido, and sexual function
Increased muscle mass and reduced body fat
Improved mood, motivation, and cognitive function
Better sleep quality and overall wellbeing
Improved bone density and cardiovascular markers

Risks & Side Effects

Suppression of natural testosterone and LH/FSH — may cause infertility while on TRT
Testicular atrophy — reduced testicular size due to suppression of natural production
Elevated hematocrit / polycythemia — monitored with periodic labs; may require dose reduction or phlebotomy
Elevated PSA — requires monitoring; TRT is contraindicated in active prostate cancer
Estrogen conversion (aromatization) — may cause gynecomastia, water retention; managed with aromatase inhibitors if needed
Acne and hair thinning in genetically susceptible individuals
Potential cardiovascular risk — use with caution in patients with pre-existing cardiovascular disease
Mood changes — aggression or irritability can occur especially at supraphysiologic doses

Fertility Disclosure

I understand that TRT suppresses sperm production and may cause temporary or prolonged infertility. If fertility preservation is a concern, I will discuss alternatives such as clomiphene citrate or human chorionic gonadotropin (hCG) with my provider before initiating TRT.

Lab Monitoring Requirements

I agree to complete required baseline labs before starting TRT (testosterone, hematocrit, PSA, metabolic panel) and follow-up monitoring labs at intervals determined by my provider, typically at 6–12 weeks and annually thereafter.

Direct-Pay & Truthfulness

I certify all information in this intake is truthful and complete. I understand payment is handled by my participating clinic or provider and outfitMD does not bill my health insurer for platform coordination. I may withdraw consent at any time without affecting my access to other services.

Identity Verification

Why we ask: Federal law, state licensing rules, and pharmacy practice standards commonly require prescribers to verify patient identity before issuing medications. Your attestation below helps meet this requirement for your initial intake. A government-issued photo ID may be requested at or before your first visit.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the risks and benefits of TRT as described above.

I understand TRT suppresses natural testosterone production and may affect fertility. I have considered this and either accept the risk or will discuss fertility preservation with my provider.

I agree to complete required baseline labs prior to starting TRT and ongoing monitoring labs as directed by my provider.

I confirm I am 18 years of age or older, am the patient named in this form, and voluntarily consent to TRT and hormone therapy with my participating clinician under the outfitMD partner program. All information provided is truthful and complete.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your full legal name above and clicking Submit, you provide a legally binding electronic signature under the federal E-SIGN Act (15 U.S.C. § 7001) and applicable state electronic signature law.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Patient Information

Symptom Assessment

Medical History

Medications & Lab Values

Goals & Lifestyle

Informed Consent & Signature

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