First Name *

Last Name *

Phone *

Email *

Date of birth *

Do you have a decrease in libido (sex drive)? *

Yes

No

Do you have a lack of energy? *

Yes

No

Do you have a decrease in strength and/or endurance? *

Yes

No

Have you lost height? *

Yes

No

Have you noticed a decreased "enjoyment of life"? *

Yes

No

Are you sad and/or grumpy? *

Yes

No

Are your erections less strong? *

Yes

No

Have you noticed a recent deterioration in your ability to play sports? *

Yes

No

Are you falling asleep after dinner? *

Yes

No

Has there been recent deterioration in your work performance? *

Yes

No

Your Low Testosterone Screening Score *

Is Your Low Testosterone Score ABOVE 3? *

Yes

No

You're pre-qualified for Testosterone Replacement Therapy!

Please continue to book your appointment today.

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