Intake Form - Men Hormone Replacement Therapy

Full Name

Phone *

Date of birth

Email *

Address

Street Address

City

State

Country

Postal Code

Sex

Emergency Contact

Family Doctor

TRT / HCG Consent

This consent form will be used if you are deemed to be eligible for Testosterone Therapy/HCG treatment. Intellimed Wellness clinicians can deem you ineligible following their assessment. *

I understand

Testosterone / HCG Evaluation

Have you ever had your testosterone levels tested? (If Yes, include levels below)

Total Testosterone:

Free Testosterone:

Date of Labs:

Have you previously used testosterone therapy/HCG? *

Yes (Prescribed - Include Form (Gel, Injection, etc.) and Duration)

Yes - (Non-Prescribed - Include Form (Gel, Injection, etc.) and Duration)

Are you interested in preserving fertility?

Yes (HCG may be recommended alongside or instead of Testosterone)

Unsure

Heath History Questionnaire

Please List

Specific Medical Histories

History of Thyroid Cancer or Tumors *

Yes

History of Multiple Endocrine Neoplasia or Tumors *

Yes

History of Fainting or Black-Outs *

Yes

Medical/Surgical History *

None

Yes

Include Year and Reason

List Your Prescribed Drugs and Over the Counter Drugs (Vitamins Included) *

None

Yes

(Name, Dosage, Frequency)

Allergies *

None

Yes

None

(List Allergies)

Exercise *

None

Mild Exercise

Occasional Vigorous Exercise

Regular Vigorous Exercise

Alcohol *

Yes

Tobacco (including Vapes) *

Yes

Family History

Testosterone Therapy / HCG and Potential Side Effects

Testosterone Therapy & HCG Treatment Consent

Testosterone Replacement Therapy (TRT) may be prescribed to help restore testosterone levels in individuals with clinically low or suboptimal testosterone. Human Chorionic Gonadotropin (HCG) may be used alongside or independently to support the body’s natural testosterone production and help maintain testicular function and fertility.

The goals of therapy may include improvement in energy, mood, libido, muscle mass, strength, body composition, cognitive function, and overall quality of life. Treatment plans are individualized based on medical history, lab results, symptoms, and clinical response.

Potential Risks & Side Effects

While many patients tolerate therapy well, potential side effects may include, but are not limited to:

Acne or oily skin
Increased body or facial hair growth
Fluid retention or swelling
Mood changes (irritability, anxiety, or mood swings)
Increased red blood cell count (polycythemia), which may increase the risk of blood clots
Elevated blood pressure
Changes in cholesterol levels
Breast tenderness or enlargement (gynecomastia)
Testicular shrinkage (with testosterone therapy alone)
Reduced sperm production or fertility (testosterone therapy alone)
Headaches
Injection site reactions (pain, redness, swelling, bruising)

Specific to HCG, additional potential side effects may include:

Abdominal bloating or discomfort
Headaches
Fatigue
Mood changes
Rare risk of ovarian hyperstimulation in females (if applicable)

Important Considerations

Testosterone therapy may suppress the body's natural testosterone production. The addition of HCG may help preserve testicular function and fertility; however, fertility outcomes are not guaranteed. Ongoing monitoring through lab work and clinical follow-up is required to ensure safety and effectiveness.

I understand that results are not guaranteed, therapy requires regular follow-up and lab monitoring, and dosage adjustments may be necessary. I acknowledge that I have had the opportunity to ask questions, understand the potential benefits and risks, and voluntarily consent to treatment.

Any prostate problems in the past?: *

None

Yes

None

if so what problems?

Are you still under current treatment? *

None

Yes

None

How often do you see your doctor for this?

Do you snore? *

Yes

Do you use CPAP or BiPAP? *

Yes

Do you have night time urinary frequency? *

Yes

Do you have poor or intermittent urinary stream? *

Yes

Check Yes for each of the statements below, if you agree with the statement.

This is my consent for Intellimed Health Inc AKA Intellimed Wellness, with any physician or nurse who is working with the company, to begin treatment of testosterone deficiency. *

Yes

It has been explained to me and I fully understand that occasionally there are complications of this treatment, which may include the items listed below. *

Yes

Acne *

Yes

Breast Enlargement *

Yes

Mood Swings *

Yes

Extra fluid in the body. This can cause problems for patients who have heart, kidney or live disease. *

Yes

Sleep disturbance. This is called sleep apnea and is more likely in patients who have lung disease or are overweight. *

Yes

Prostate Enlargement which may cause problems with urinating *

Yes

Changes in cholesterol levels, red blood cells, PSA levels, and liver function enzymes, and other hormone levels which will be monitored with periodic blood tests. *

Yes

I understand that testosterone replacement may increase complications and adverse outcomes, including death, for those with known heart disease. If I am under 65 with known heart disease I must be cleared by a Cardiologist or my primary care provider. If I am 65 years or older, with or without known heart disease, I must be cleared by a Cardiologist or my primary care provider. *

Yes

I understand that Testosterone Therapy has been associated with an increased risk of developing blood clots (thrombosis). I acknowledge that I have been informed of this potential risk and provide my consent to proceed with the therapy, fully aware of the possible complications. *

Yes

I understand there is no warranty or guarantee as to the result and that my condition may return or become worse. *

Yes

I have had, or understand that I will have, an opportunity to discuss with Intellimed Wellness and its medical practitioners my complete past medical and health history including any serious problems and/or injuries. All of my questions concerning the risks, benefits, and alternatives have been answered or, if they have not been answered, I understand that I may follow up before I begin treatment. I will start treatment only after I am satisfied with the answers to all of my questions. *

Yes

I understand that the physical exam by Intellimed Wellness does NOT replace a full physical exam by a personal physician. *

Yes

I agree to have my personal physician perform a yearly full physical exam including a digital rectal exam, lipid profile, cholesterol levels, and a comprehensive metabolic panel. If I do not have a personal physician, Intellimed Wellness will assist in locating one for me. *

Yes

FERTILITY - I understand that the use of exogenous testosterone may result in testicular atrophy as well as lowering of my sperm count that can diminish my fertility/ability to father a child while on therapy and for an indeterminate time into the future. *

Yes

Certain medical authorities recommend HCG to be given twice weekly to minimize testicular atrophy and to increase fertility/ability to father a child. *

Yes

I understand that normal ranges for testosterone are generally established by reference to morning levels and that men's testosterone levels generally decline in the afternoon. *

Yes

I understand that men's testosterone levels can vary significantly between tests, even when the tests are conducted at the same time of day. *

Yes

I understand that the Intellimed Wellness treatment protocol recommends testosterone replacement therapy if I have a total testosterone level of less than 400 nanograms per deciliter, 430 nanograms per deciliter and certain symptoms, or 600 nanograms per deciliter if my free testosterone is below 11 nanograms per deciliter. I also understand that according to the Endocrine Society Guidelines, the threshold for testosterone replacement therapy should be in the range of 200 to 300 nanograms per deciliter. *

Yes

I understand that certain medical guidelines, including the Endocrine Society Guidelines and the guidelines of the American Urological Association, state that blood tests for the purposes of diagnosing hypogonadism should be performed in the morning and that two morning tests should be performed before starting patients on TRT. The Mayo Clinic consensus guidelines and our own Intellimed Wellness protocol do not include such a recommendation. *

Yes

Urinary Questionnaire

Do you feel pain or burning with urination? *

Yes

Any blood in your urine? *

Yes

Do you feel burning discharge from penis? *

Yes

Has the force of your urination decreased? *

Yes

Have you had any kidney, bladder, prostate infections within the last 12 months? *

Yes

Do you have any problems emptying your bladder completely? *

Yes

Any difficulty with erection or ejaculation? *

Yes

Any testicle pain or swelling? *

Yes

Exams

Date of last prostate and rectal exam?

Date of last colonoscopy?

Are There Any Other Health Complications that Intellimed Wellness Should Be Aware of?

I agree, while a patient of Intellimed Health Inc and Intellimed Wellness, I will not take any type of anabolic steroids, testosterone gels, hormone "boosters", pro-hormones or any additional testosterone supplementation not provided by Intellimed Wellness during my treatment plan. At any time, if use of these items is discovered, I understand I may be discharged as a patient of Intellimed Wellness. I further agree to hold Intellimed Wellness harmless from, and not to bring any action resulting from, any result, outcome, damage, loss or other effect due to my non-compliance with the promises set forth in this document.

Patient Signature

Clear

Blood Draw Consent

I give my consent to the staff at Intellimed Wellness to draw a blood sample in order to check my Complete Metabolic Panel (CMP), Prostate-Specific Antigen (PSA), Complete Blood Count (CBC), Thyroid-Stimulating Hormone (TSH), Estradiol (E2), Testosterone (Full). *

Yes

I understand that the only test that will be run at this time is a Complete Metabolic Panel (CMP), Prostate-Specific Antigen (PSA), Complete Blood Count (CBC), Thyroid-Stimulating Hormone (TSH), Estradiol (E2), Testosterone Full and that other test(s) may be necessary to determine my treatment plan. If more tests are required, I give my consent to "add on" tests if the same sample can't be utilized. *

Yes

I understand that my personal information and lab results will not be shared without my permission, as per HIPAA guidelines. *

Yes

Signature *

Clear

By selecting the following option, do you consent to having your testosterone replacement therapy (TRT) prescription forwarded to the nearest pharmacy for fulfillment? Additionally, do you acknowledge that you will not hold Intellimed Wellness responsible for any self-administration of the prescribed medication? *

Yes I consent

By agreeing to the aforementioned terms, you also authorize Intellimed Wellness to bill you on a monthly basis for refilling your prescription. You understand that it is your responsibility to call prior to the next month to cancel the membership. Please note that once billed for the month, there will be no refunds issued for membership fees. *

Yes I consent

Accuracy of Information

I certify that the above medical information is correct to my knowledge.

Privacy and Sharing of Information

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

I agree

Cancellation policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the physician or nurse practitioner’s day that could have been filled by another patient. As such, we require 3 hours notice for any cancellations or changes to your appointment. Patients who provide less than 3 hours notice, or miss their appointment, will be charged a cancellation fee to the card on file.

I am aware of the Cancellation Policy.

SMS Consent

I agree to receive promotional and appointment-related text messages from Intellimed Wellness. Message frequency varies. Msg & data rates may apply. Reply STOP to unsubscribe.

I agree

I disagree

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