IMH T Program

Basic Health Information

Provide all details about your medical condition for initial visit

Please identify all your current medical conditions *

Please list all your current medications including dosages *

Please list all of your known allergies *

What is your height in feet and inches? *

What is your weight in pounds? *

Please explain any issues during your last physical exam *

Your BMI is: *

Please provide further details *

Medical History

Provide all details about your medical history

Please select the option that best describes you: *

I do NOT have a known diagnosis of low testosterone

I have a known diagnosis of low testosterone and I AM currently or have previously been on testosterone replacement therapy

Did you know that testosterone replacement therapy (TRT) can lower your sperm production and may reduce fertility, so if you’re actively trying to conceive then TRT may not be the best option for you at this time. Do you understand the risks associated with TRT and how it may impact your fertility? *

I understand the risk and I’m not planning on having children and would like to continue with treatment

I am planning on having children and would be interested in alternatives such as enclomiphene

I AM planning on having children soon and would like to cancel

Do you have known sleep apnea? *

Yes

No

Testosterone therapy can worsen existing sleep apnea or reveal previously undiagnosed sleep apnea. If you notice increased snoring, gasping at night, morning headaches, excessive daytime fatigue, or if someone observes breathing pauses during your sleep, please notify us immediately. Untreated sleep apnea can lead to low nighttime oxygen levels and added strain on your heart. If you already have sleep apnea and are not consistently using your CPAP or other treatment, TRT may increase your risk of complications. Please keep us informed of any symptoms so we can ensure your treatment remains safe. *

I have read and understand this information and I wish to proceed

I have read and understand this information and I do NOT wish to proceed

What other information or questions do you have for the doctor? *

Symptoms

Provide all details about your medical symptoms

Authenticate Yourself

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Personal Information

Please provide a few personal informations

What was your sex assigned at birth? *

Male

Female

What is your current gender identity? *

Man

Woman

Transgender male

Transgender woman

Non-binary

What is your Date Of Birth? *

Shipping Information

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Name: *

Phone Number: *

Street Address *

Apt/Suite

City *

Zip *

State *

Country *

Identity Verification

Upload a photo of a valid government-issued photo ID such as a driver’s license or passport which has your picture, name and date of birth clearly visible. If applicable, upload a photo of the front and the back especially when using a military ID as your date of birth is on the back of the card. Make sure the photo is clear and legible.

Max allowed file size should be less than 5MB.

Select Photo

Your Consent

Consent (Truthfulness):

Please attest to the following confirming that all information you have provided to us is true and complete. I confirm that the medications that I take and my medical history are accurate.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. Testosterone therapy is considered a controlled medication. I confirm that the provider can review my controlled medication use through the Prescription Drug Monitoring Program (PDMP). I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

I have read the above information and I do consent and wish to move forward

I have read the above information and I do not wish to continue

Testosterone Replacement Therapy (TRT) Informed Consent

You are requesting evaluation and possible treatment with Testosterone Replacement Therapy (TRT) to address symptoms related to low or declining testosterone levels. Testosterone may be prescribed as a transdermal cream, gel, nasal spray, or injection, depending on your clinical evaluation and laboratory results. I understand that this program involves a licensed healthcare provider's evaluation and ongoing medical supervision. Non-medical staff and wellness coaches do NOT prescribe or adjust medication.

Potential Benefits

Control or reduction of symptoms associated with testosterone deficiency (e.g., fatigue, sleep disturbances, low libido, erectile dysfunction, muscle loss, or mood changes).
Possible improvement in body composition, bone density, and overall sense of well-being.
Potential prevention or improvement of physical diseases and dysfunction related to declining hormone levels.

Potential Risks and Side Effects

While TRT can be beneficial, it carries risks that may require medical attention. Side effects can range from mild to serious.

Common side effects may include:

Pain, bruising, or infection at the injection site (for injection preparations)
Acne, oily skin, or hair loss
Fluid retention or swelling
Mood changes or irritability
Testicular shrinkage and decreased sperm production
Elevated red blood cell count
Skin transfer risk (for topical preparations)

Serious or rare adverse effects may include:

Elevated liver enzymes or liver inflammation
Polycythemia (requiring phlebotomy or dosage adjustment)
Worsening of sleep apnea
Prostate enlargement or stimulation of preexisting prostate cancer
Cardiovascular complications, including blood clots, stroke, or heart attack
Allergic reactions, including rash, swelling, or anaphylactoid response
Infertility (temporary or permanent)

If you experience chest pain, shortness of breath, vision changes, leg swelling, or severe headache, stop treatment immediately and seek emergency medical attention (call 911).

Bioidentical or Compounded Testosterone

Some testosterone products may be prepared by compounding pharmacies and are considered non-FDA-approved formulations. Bioidentical or compounded testosterone products are used when commercial formulations are unavailable, not tolerated, or do not fulfill your personalized need. Evidence comparing the safety or cardiovascular risk profile of compounded versus FDA-approved testosterone products remains inconclusive.

Fertility and Family Planning

Testosterone therapy can suppress sperm production and lead to temporary or permanent infertility. If fertility preservation is desired, alternative therapies such as clomiphene citrate (Clomid) or enclomiphene may be discussed.

Clomid may cause visual changes, nausea, vomiting, or rare liver or lipid abnormalities. Any vision disturbances should prompt immediate discontinuation and ophthalmologic evaluation.

Contraindications

You confirm that you have disclosed any history of:

Prostate or breast cancer
Uncontrolled sleep apnea
Severe heart disease or stroke
Polycythemia (elevated hematocrit)
Hypersensitivity to testosterone or formulation ingredients

TRT is contraindicated in these conditions. Hypercalcemia may occur in immobilized patients. Older men on TRT may have a higher risk of prostate enlargement, though evidence remains inconclusive.

Cardiovascular, Clotting, and Sleep Apnea Risks

TRT may increase red blood cell production, potentially thickening the blood. This may contribute to cardiovascular strain, hypertension, or increased risk of clotting in susceptible individuals.

Patients with sleep apnea may experience worsening symptoms and should report any snoring, daytime sleepiness, or witnessed apnea episodes.

Monitoring and Laboratory Testing

I understand that ongoing therapy requires periodic laboratory monitoring to ensure safety and effectiveness.

Typical testing includes:

CBC (hematocrit and hemoglobin) – monitor for red blood cells
PSA (prostate-specific antigen) – assess prostate health
Liver function tests and lipid panel – monitor metabolic effects
Testosterone levels – confirm therapeutic response

These labs are usually obtained every 3 months or every month if the dose is adjusted and are required for continuation of therapy. Failure to complete lab testing may result in discontinuation of treatment.

Alternatives to TRT

Doing nothing and monitoring symptoms.
Treating symptoms of low testosterone with non-hormonal approaches.
Lifestyle modification, improved nutrition, and management of comorbid conditions.

Medical Oversight and Program Participation

This program involves the medical judgment and supervision of a licensed healthcare provider.
Regular follow-up visits and laboratory monitoring are required.
I should immediately report any adverse effects or changes in my medical history to my provider.

I acknowledge that I have read and understand the information provided above regarding Testosterone Replacement Therapy. I understand the potential benefits, risks, alternatives, and required monitoring. I consent to treatment with Testosterone Replacement Therapy under the supervision of my healthcare provider.