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To see if you qualify for TRT treatment please fill out the Medical Questionnaire. Once completed, this will be reviewed by our medical doctor and we will send you a pre-qualification approval or denial email based on the information provided.
1. Have you previously received any hormone replacement therapy?*
- Yes
- No
Please provide more information*
2. Have you ever experienced any negative reactions (adverse effects) to hormone replacement therapy?*
- Yes
- No
Please provide more information*
3. Within the last six months have you been under a physician’s care?*
- Yes
- No
Please provide more information*

4. Are you currently on any medication including dietary supplements, vitamins, aspirin, steroids, anticoagulant, diuretics or slimming tablets?*
- Yes
- No
Please provide more information*
5. Have you ever been admitted to hospital?*
- Yes
- No
Please provide more information*
6. Have you had previous surgical procedures?*
- Yes
- No
Please provide more information*
7. Have you ever experienced severe allergy / anaphylaxis to product/treatment/medication?*
- Yes
- No
Please provide more information*

Consent*
I herewith agree to the following:
1.1 That the staff of the centre perform the treatment(s) and that they are not held liable for any guarantee, warranty or assurance of the results that may be obtained
1.2 I certify that I am a competent adult of at least the age of eighteen and this is my free and voluntary decision that is executed;
1.3 I have answered all the questions contained herein with accuracy, honesty and to the best of my ability. If there are changes to my medical history, operations or medications I will be responsible for informing the centre of the updates and any other serious conditions that may be relevant;
1.4 I agree to adhere to all safety precautions and regulations during the treatments and to follow all instructions;
1.5 The centre does not take responsibility for treatments done with other practitioners or centres that may cause side effects to the therapy
1.6 My digital submission of this form indicates my informed consent to the therapy and my acceptance of the conditions outlined herein.
Consent*
I have read and understood the treatment information guide relating to my therapy. I have been advised that all treatments may differ due to variables such as age, lifestyle etc.

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