Testosterone Replacement Therapy
Weight Loss + Metabolic Support
Apollo VIP Treatment
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How It Works
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Patient Name and Your Relationship to Patient
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Treatments Interested In
Testosterone Replacement Therapy
Apollo VIP Package
How Did You Hear About Blokes?
Google / Search Engines
Labs Interested In
Comprehensive Wellness Panel
Current Weight (lb)
Current Height (in)
Date of Your Last Physical Exam
Type "N/A" if Not Applicable
Were there any abnormal findings in your last exam?
Do you have a history of high blood pressure?
What brings you into the clinic today?
What’s your primary concern?
Please list all known allergies.
Please list all medications you are currently taking
Include dosage and times per day
Are you currently trying to conceive?
Are you planning to have children in the future?
What is your current occupation?
Do/did you smoke/vape tobacco?
I am a former smoker who quit
How many years since you have quit?
How often do you consume alcoholic beverages?
I am a former drinker who quit
Approximately how many drinks do you consume in one sitting?
How often do you consume recreational drugs?
I am a former user who quit
How often do you exercise?
What type of exercise?
Review of Systems
Recent Weight Gain
Recent Weight Loss
Low Blood Pressure
High Blood Pressure
Joint Pain/ Disease
Anything else you want to tell us regarding your past medical history?
History of cancer?
Please check all the symptoms that apply
Lack of energy/constant fatigue
Lack of drive/motivation
Low/poor sex drive
Inability to achieve an erection
Inability to maintain an erection
Muscle loss/decreased muscle strength
Poor mental focus
Weight gain (specific to belly)
Hair Loss, Overweight, etc
Emergency Contact Name
Emergency Contact Phone
If you don't have your previous lab results from sometime in the last 90 days, please skip this step and click "NEXT" down below and we will schedule labs on your behalf. If you do have lab results from the last 90 days, please upload the results here.
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Health Care Services Consent
I understand by signing this Health Care Services Consent ("Consent"), I give my consent to receive professional health care services from Blokes rendered by a health care provider that treats me through a telehealth platform. Professional care may include, but not limited to, review of information I have provided or questions answered prior to an telehealth examination, a telehealth examination or consultation, prescription of medication, and provision of any follow-up care, as needed. I understand Blokes is a telehealth medical practice; and I may receive treatment from multiple providers, my protected health information may be shared among the providers in connection with my treatment and pursuant to the Practices’ privacy policies.
I allow Blokes, from which I receive services, to obtain access to my medication history for treatment purposes, through integrative electronic prescribing platforms and/or computer networks operated by providers of electronic prescribing services. I understand that I may withhold or withdraw my consent regarding access to my medication history through the electronic prescribing platforms
and/or computer networks per the process described below, which will not affect my ability to receive medical care.
I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury and/or a serious adverse event. I understand that there are risks and benefits when receiving any health care services and that the risks and benefits of such care will be explained to me and I will have the opportunity to ask my health care providers, questions about such risks and benefits. Services rendered by Blokes Providers are not intended to replace your primary care medical services.
I acknowledge that no guarantees have been made to me regarding the result of a diagnosis or treatment provided to me by my Blokes Provider. As with any other medical services, some patients do not respond to prescribed treatment.
I have disclosed all my known health conditions, allergies, and medications/supplements I am taking. I understand that certain treatment options that I may receive from or medications prescribed to me by my Blokes Practice Provider can be dangerous and may result in medical care that is unnecessary if I have misrepresented my current health care condition and status. I have truthfully supplied information about my health care condition and status in response to any health related questions prior to, during
any in-person examination with my Blokes Provider, and after an exam.
I understand that the terms herein are contractual and not a mere recital and that I sign to agree with this document as my own free act and not of any coercion. The permissions granted herein shall begin on the date I agreed to this document and shall remain effective until terminated by me. I understand I have the right to withhold/withdraw my consent at any time by submitting a request via email to firstname.lastname@example.org
I verify I have read all of the information contained in this Consent. I understand I will have the opportunity to ask my Blokes Provider about anything I have not understood up to this point.
TERMS AND CONDITIONS OF PAYMENT
Receipt of health care services from Blokes and a Blokes Provider and your use of the Blokes, LLC Internet Platform (the “Platform”) in connection with such health care services, constitutes an ongoing agreement to these Terms and Conditions of Payment (the “Terms and Conditions”). Capitalized terms used herein but not otherwise defined shall have the meaning given to such terms in the above Health Care Services Consent. Insurance Not Accepted; Your Responsibility for Payment
INSURANCE NOT ACCEPTED; YOUR RESPONSIBILITY FOR PAYMENT
I understand and acknowledge that Blokes from whom I receive care and the pharmacies that receive prescriptions from such Blokes per the Platform, are not paid or reimbursed by managed care plans, Medicare, Medicaid or other government health care programs, or other third-party payors. Blokes does not accept insurance for such services. Except as otherwise explicitly stated herein, I will be
billed directly and shall be personally responsible for payment, regardless of whether I am or will be reimbursed by a managed care plan or other third-party payer.
I agree to make timely payments for all health care, laboratory and pharmacy services that are
provided to me. I understand by providing my payment information on the Platform, including but not limited to any credit card information or credit card hold information for future payments, I authorize Blokes, LLC to charge the credit card or other payment method for all items and/or services I receive or are scheduled to receive from the Blokes Provider providing my care, the laboratories and the pharmacies. I understand when I receive services, from Blokes, the cost of services (including medical care, laboratory, and prescription costs remitted directly to the laboratories and pharmacy on my behalf) is calculated and services are provided on an agreed upon basis, and I will be billed for
payment (even if I do not receive medical services or prescriptions in more than one month of the plan for which I am billed). I understand I have the choice to pay for my program cost upfront, in-full for the year (at significant savings), or in monthly, or every other month payments. I understand I am
responsible if I cancel before my agreed upon program is completed, for a prorated cost of my
program even if I discontinue as a patient before completing payment monthly or every other month plan I’ve agreed to. I understand that the cost of services, including labs, medications, are final and not refundable. This is because the cost of treatment is for professional medical services (including any blood draws) which are fully rendered at point of care. Pharmacy rules prohibit the return of medications for reimbursement because medications are packaged for you and cannot be used for
another patient. I understand I will not be able to receive refunds for treatments and for medications, even if they are unused. I understand that Blokes reserves the right to discontinue service if I am delinquent on any payments, for which I am responsible.
I understand and agree to provide a 30 day notice prior to stopping treatment. I agree to have a final visit with a Blokes Provider, in order to safely discontinue use of the medications used in my treatment plan.
Any and all controversies, claims, or disputes arising out of, relating to, or resulting from these Terms and Conditions of Payment shall be subject to the arbitration provisions as set forth in the Terms & Conditions at www.blokes.co The provisions of these Terms and Conditions of Payment shall be severable, and if any provisions shall be prohibited by law, invalid, or unenforceable in whole or in part for any reason, the remaining provisions shall remain in full force and effect.
I understand that by signing this form, I am agreeing to the foregoing Health Care Services Consent and Terms and Conditions of Payment.
I understand and am agreeing to the foregoing Health Care Services Consent and Terms and Conditions of Payment.
Informed Consent for Hormone Therapy
The following information is provided to assist you with making an informed decision regarding the use of testosterone or other hormone therapies (which include but are not limited to testosterone cypionate, human chorionic gonadotropin (hCG), and anastrozole) which may be prescribed to you by a Blokes practitioner during the course of your treatments.
Please review the information below and ask any questions you have about it.
Testosterone is a controlled medication with risks and benefits. Some potential benefits of
testosterone and other hormone therapies include:
Improvement in energy; improvement in sexual desire; decrease in fatigue; improvement in depressive symptoms; increase in muscle mass; and increase in bone density.
Some known or potential risks of testosterone therapy and other hormone therapies, include (but are not limited to):
Worsening of cholesterol (in particular, “good” HDL); increases in hematocrit (blood thickness); breast tissue growth, swelling, or tenderness (gynecomastia); elevated blood pressure; water retention or swelling of arms or legs (edema); blood clots in the legs, lungs, or brain; increased risk of cardiovascular or cerebrovascular events; lowering of sperm counts, possibly to the point of infertility; acne and male pattern baldness; reduced testicular size; skin-to-skin transference to a partner or child (topical therapy); skin irritation (topical therapy); prostate cancer progression; breast cancer progression; liver dysfunction (oral therapy); potential for abuse and dependence.
I understand that during the course of treatment I may or may not feel or develop any of these
benefits and/or risks and that I will have the opportunity to further discuss these potential benefits and risks with my provider.
Hormone therapy requires close monitoring and regular examinations during the course of my
treatment. I therefore agree to have the appropriate laboratory testing and examinations as recommended.
There is some risk of enhancing an existing current prostate cancer to grow more rapidly. For this reason, a prostate specific antigen blood test is to be done before starting testosterone therapy and will be conducted at a minimum each year thereafter. If there is any question about possible prostate cancer, a follow-up with an ultrasound of the prostate gland may be required as well as a referral to
a qualified specialist. While urinary symptoms typically improve with testosterone, rarely they may worsen, or worsen before improving.
Testosterone therapy may increase one’s hemoglobin and hematocrit or thicken one’s blood. This problem can be diagnosed with a blood test. Thus, a complete blood count (Hemoglobin and Hematocrit) should be done at least annually.
Hormone therapy may require having a therapeutic phlebotomy performed if hematocrit levels become too high, and I agree to follow these requirements if needed. I also understand that I will only be eligible to continue receiving the medication(s) if I am up to date with my examinations, laboratory work, and any necessary therapeutic phlebotomies.
I certify that I have received and understand this information and had my questions answered. I also understand that I have the option to not take testosterone therapy at any time.
I agree to proceed with treatment understanding that testosterone may cause an increase in prostate size and increase in PSA levels. Patients are required to undergo PSA blood testing and digital rectal exam (when clinically appropriate) on a routine basis as recommended by your provider. Testosterone restoration is contraindicated in patients undergoing active prostate cancer treatment or known prostate cancer (with some exceptions as agreed upon by patient and provider).
I understand and consent to treatment
Aromatase Inhibitors Usage and Understanding
Aromatase Inhibitors (Anastrozole) utilization: Although the prime indication for these types of medications is in the treatment of breast cancer in women, there is increasing utilization of this medication in men. Aging men, men who are overweight, and those who are genetically predisposed can have “estrogen excess” due to converting (aromatization) too much of their testosterone to estrogen. Our fat cells contain the enzyme "aromatase" which promotes this conversion. This estrogen conversion can lower a man’s testosterone levels but also cause estrogen to spike to higher levels causing negative consequences and side effects. Estrogen excess can cause gynecomastia (breast enlargement), hot flashes and night sweats, infertility, impotence, mood changes, prostate enlargement and increased risk for prostate cancer.
I understand and consent to treatment using Aromatase Inhibitors
Authorization and Consent to Participate in Telemedicine/telehealth Consultation
The purpose of this form is to obtain your consent to participate in a telemedicine consultation with
1) Nature of Telemedicine Consultation: During the telemedicine consultation:
a) Details of you and/or your medical history, examinations, and laboratory tests will be discussed with other health professionals
through the use of interactive video, audio and telecommunications technology. b) Physical examination of you may take place. c) Nonmedical technical personnel may be present in the telemedicine studio to aid in video transmission. d) Video, audio, and/or digital photo may be recorded during the telemedicine consultation visit.
2) Medical Information and Records.
All existing laws regarding your access to medical information and copies of your medical records apply to this telemedicine consultation. Additionally, dissemination of any patient-identifiable images or information from this telemedicine interaction to researchers or other entities shall not occur without your consent, unless authorized under existing confidentiality laws.
Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with the telemedicine consultation. All existing confidentiality protections under federal and state law apply to information disclosed during this telemedicine consultation.
4) Risks and Benefits.
The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.
My health care practitioner has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I understand the written information provided above.
I acknowledge receipt of Blokes Authorization and Consent to Participate in Telemedicine/Telehealth Consultation.
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