Consent & Legal Acknowledgement

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Medical Intake Information

Personal Information

Please confirm your basic contact and physical details.

First Name

Last Name

Email

Date of birth

Biological sex

Height

Weight

Symptom Screening

These details are required to correctly interpret blood results and assess suitability for TRT.

Low energy or fatigue

Low libido or sexual health concerns

Poor recovery from exercise

Mood or motivation issues

Muscle or body composition concerns

Poor concentration or brain fog

Tell the doctor how you are feeling

Medical Red-flag Screening

Please answer accurately for your clinical Safety

Have you ever been diagnosed with prostate cancer?

Yes

No

Have you had a heart attack or stroke in the past 12 months?

Yes

No

Do you have untreated sleep apnea?

Yes

No

Do you have polycythaemia or high haematocrit?

Yes

No

Are you currently using testosterone or anabolic steroids?

Yes

No

Current Medication

List all prescriptions, OTC drugs, and supplements.

Are you currently taking any prescription medication?

Yes

No

Please list the medication(s)

Previous Blood Work

Recent labs can expedite your treatment plan.

Have you had blood tests done in the past 6 months?

Yes

No

Please upload the results (PDF or image)

Choose File

Legal Confirmations

Required acknowledgements for telemedicine services.

I confirm that the information provided above is accurate and complete to the best of my knowledge

I accept the Terms & Conditions

I consent to the Privacy Policy (POPIA)

I understand this is a telemedicine service and not emergency care

Redefining longevity through precision medicine and restorative clinical protocols.

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