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Basic Info
Emergency Contact
Health History
Cardiovascular Disease
Respiratory Disease
Gastrointestinal Disease
Genitourinary Disease

Please check Yes or No if you have ever had any of the following:

Heart Attack/Heart Disease
DVT/Blood Clots
Prostate Cancer
Illicit Drugs
Current Health Questionnaire

Please check Yes or No if you currently have any of the following:

Pain or burning during urination
Blood in urine
Burning or discharge from penis
Decreased urine force
Kidney, bladder or prostate infection in the last 12 months
Problems emptying your bladder completely
Difficuly with erections or ejaculation
Testicle pain or swelling
Difficulty concentrating
Weight gain
Decreased sex drive
Increasing fatigue
Decreased energy
Daytime sleepiness
Poor sleep habits
Erectile Dysfunction
Had a prostate or rectal exam
Consent for Testosterone Replacement Therapy

It is important to understand that medicine is an inexact science. Although we will carry out your treatment carefully, results can vary in their degree of success. It is very important for you to be aware of the potential risks, as well as benefits, expected from treatment when deciding on whether to begin TRT.

Please review the following. Any questions that you may have should be brought to our attention. Your clinical provider will attempt to answer all questions to your satisfaction. 

Notice of Privacy Practices
As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996(HIPAA)

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information. 
Please review this notice carefully.

A. Our commitment to our privacy
Our practice is dedicated to maintaining the privacy of your individual identifiable health information (IIHI). In conducting our business, we will create records regarding you and your treatment and the services we provide for you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your IIHI. By federal law and state law, we must provide you with the following important information:

  • How we may use and disclose your IIHI

  • Your privacy rights in your IIHI

  • Our obligations concerning the use of disclosure of your IIHI

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the rights to revise or amend this notice or privacy practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that may create or maintain in the future.

B. We may use and disclose your individually identifiable health information (IIHI) in the following ways:


Treatment. Our practice may use your IIHI to treat you.  For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. Any of the people who work for our practice- including, but not limited to, our doctors and nurses, or indirectly with any provider we refer you to- may use or disclose your IIHI to others who may assist in your care, such as your spouse, children, or parents. 


Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment and health status to determine if your insurer will cover, or pay for, your treatment. We may also use and disclose your IIHI to obtain payment from third parties that may use your IIHI to bill you directly for services and items. 


Health care operations. Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you receive from us, or to conduct cost management and business planning activities for our practice. 


  • Appointment reminders. Our practice may use and disclose your IIHI to contact you or a family member who answers the phone (or o leave a recorded message) to remind you of an upcoming appointment.

  • Treatment options. Our practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.

  • Health related benefits and services. Our practice may use and disclose your IIHI to inform you of health options or alternatives. 

  • Release of information to family/friends. Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to our office for care. In this example, the babysitter may have access to this child’s medical information with written consent. 

  • Disclosures required by law. Our practice will use and disclose your IIHI when we are required to do so by federal, state, or local law. 

C. Use and Disclosure of your IIHI in certain special circumstances. The following categories describe unique scenarios in which you may use or disclose your identifiable health information:


Public health risks. Our practice may disclose your IHHI to public health authorities that are authorized to collect information for the purpose of: 

  • Maintaining vital records, such as birth and death.

  • Reporting child abuse or neglect.

  • Preventing or controlling a disease, injury or disability.

  • Notifying a person regarding potential exposure to a communicable disease or condition.

  • Notifying a person regarding a potential risk for spreading or contracting a disease or condition. 

  • Reporting reactions to drugs or problems with products or devices.

  • Notifying individuals if a product or device they are using has been recalled.

  • Notifying appropriate government agency and authorities regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.

  • Notifying your employer under limited circumstances related to primarily workplace injury or illness or medical surveillance.

Health oversight activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example. Investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general. 

Lawsuits and similar proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but the party has requested. In general, we will require that the party that requests your records provide a records release form, signed by you within the last 3 months. 

Law enforcement. We may release IIHI if asked to do so by law enforcement official:

  • Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement.

  • Concerning a death, we believe has resulted from criminal conduct.

  • Regarding criminal conduct at our office.

  • In response to a warrant, summons, court order, subpoena or similar legal process.

  • To identify/locate a suspect, material witness, fugitive or missing person.  

  • If an emergency, to report a crime (including the location or victim of the crime, or the description, identify or location of the perpetrator.

Deceased patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.  

Organs or tissue donation. Our practice may release your IIHI to organizations that handle organ, eye, or tissue procurement or transplantation, including organ donation banks, necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

Research. Our practice may use and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when our use or disclosure was approved by an institutional review board or a privacy boar; or we obtain the oral or written agreement that the IIHI is used for research.

Serious threats to health or safety. Our practice may use your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of other. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat. 

Military. Our practice may disclose your IIHI if you are a member of the US or foreign military forces (including veterans) and if required by the appropriate authorities. 

National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations. 

Inmate. Our practice may disclose your IIHI to correctional intuitions or law enforcement officials if you are an inmate or under the custody of the law enforcement official. 

Workers compensation. Our practice may release your IIHI for workers compensation and similar programs. 

I have received and reviewed the privacy practice for Elevate Medical and understand the situations in which this practice may need to utilize or release my medical records. I also understand that I agreed to the use of those records when I initially applied for the care this office (my application for Care) on my first visit, whenever that may have occurred. 

I understand that this office will properly maintain my records and will use all due means to protect my privacy as outlined in this privacy practices statement. 

Final Disclosure

I agree, while a patient at Elevate Medical, I will not take any type of anabolic steroid, testosterone gel, hormone boosters, pro-hormone, or any other additional testosterone supplementation not provided by Elevate Medical during my treatment plan. At any time, if the use of these items is discovered, I understand I may be discharged as a patient of Elevate Medical. 

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