Testosterone Replacement Therapy Consultation

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Name(Required)

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Email(Required)

Phone

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Are you currently using testosterone replacement therapy?(Required)

Yes

Who first started you on testosterone treatment?(Required)

My GP

A Specialist Doctor

I have not seen a doctor about using testosterone treatment

Other

Please Provide more details(Required)

Please choose the treatment that you're currently using(Required)

How do you use this?(Required)

How much and how many times a day

What treatment and dose are you currently using?(Required)

Have you experienced any side effects from your treatment?

Yes

Please tell us more about your side effects(Required)

Have you ever had any type of cancer?(Required)

Yes

What type of cancer have you had?(Required)

Prostate cancer

Breast cancer

Other cancer

Please provide more details:(Required)

Do you have any other health conditions?(Required)

Yes

Please provide more details:(Required)

Do you plan on having children in the future(Required)

Yes

Fertility consent(Required)

Testosterone treatment can affect fertility. You should not use this treatment if you plan to have children in the future. Please tick to confirm that you understand this.

Are you currently using any medication, even if you’re not taking it regularly? Or have you finished a course of medication in the last month?(Required)

Including over-the-counter medications and herbal treatments

Yes

Please select all of the relevant medications:(Required)

blood thinning medications

steroid medications

other medications

Please tell us the name of the medication and what you use it for.(Required)

Are you allergic to any medicines or other substances?(Required)

For example lactose.

Yes

Please provide more details:(Required)

Are you currently registered with a UK GP practice?(Required)

Yes

I don't know

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To be able to prescribe this medication for you, we will need GP details. This is due to regulations issued by the General Pharmaceutical Council and so that we are able to ensure that you are receiving the appropriate follow up and monitoring. We will not be able to prescribe this medication without these details.

Surgery Full Name(Required)

Email(Required)

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Testosterone Replacement Therapy Consultation

Find out if you are eligible with our quick medical assessment.

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