New Patient Form

New Patient Medical History

(Androgen Deficiency in Aging Male) This basic questionnaire can be very useful for men to describe the kind and severity of their low testosterone symptoms.

Erectile Dysfunction issues are often intertwined with Hormonal Imbalances. Answer as honestly as you can to better evaluate underlying cause(s).

At the end of this section add the numerical score to see your outcome.

General symptoms related to ED, HRT, TRT and or other hormone imbalance issues.

Read each statement and check the number of boxes that apply for each section.

It is important to understand that medicine is an inexact science. Although we will carry out your treatment carefully, results may vary in their degree of success. It is quite natural for a patient undergoing Testosterone and or Hormone Replacement Therapy to want to know that everything will turn out all right. While most of the time this is the case, it is very important for you to be aware of the potential risks, as well as the benefits, expected from the treatment when deciding on whether to begin Hormone Replacement Therapy. You should also be aware of the alternatives to Testosterone and or Hormone Replacement Therapy, including not receiving the treatment. It is important that you consider the information we have provided you. Be sure that you are doing what is right for you. If you are unsure, then perhaps you should take some time to weigh your options or consult another health care provider. Please review the following statements, which discuss informed consent. Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all your questions to your satisfaction.

You authorize Peak Male Institute/Men’s Complete Health, LLC to release to government agencies, insurance companies, or other third-party payers and their agents, and its collection representatives and attorneys, the following “Patient Information”: medical history, diagnoses and procedures performed, course of treatment, plan of care, prognosis, supplies and/or such other information that may be requested for the purpose of determining eligibility and availability of Patient’s benefits, obtaining authorization/payment for Patient’s health care services, or billing and collection of amounts due to Peak Male Institute/Men’s Complete Health, LLC for services rendered. In the case of Patient Information released for purposes of payment of Patient Charges, this authorization shall be valid only for the period of time necessary to process payment claims. You further authorize any individual health care professional, including treating physician(s), to provide Peak Male Institute/Men’s Complete Health, LLC or its designee with Patient Information for quality assurance and, or risk management purposes. Finally, in the event that the Patient’s employer, or an insurance company representing such employer, request Patient Information relating to healthcare services provided for worker’s compensation injuries, it is understood and agreed that Peak Male Institute/Men’s Complete Health, LLC is required, under Florida law, to release copies of such information to such employer or insurance company without the authorization of Patient or Patient’s representative.

By adding my signature below I confirm and agree that while a patient of Peak Male Institute (DBA-PMI) I will not take any type of anabolic steroids, testosterone gels, hormone “boosters,” pro- hormones or any additional testosterone supplementation not provided by Peak Male Institute (DBA-PMI) during my treatment plan. At any time, if use of these items is discovered, I understand I may be discharged as a patient of Peak Male Institute (DBA-PMI).