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IRPBC
2019-07-05T20:28:41-04:00
Low Testosterone Page 2
Please fill out the rest of this form
Name
Phone
Email
Zip Code
ZIP / Postal Code
Do you have Cardiovascular Disease:
Yes
No
Unsure
Date of Birth
Date Format: MM slash DD slash YYYY
What Pre-Existing Cardio Vascular Disease do you have?
Coronary Artery Disease
Cerebrovascular Disease
Peripheral Arterial Disease
Heart Attack
Stent
Stroke
Other
Have you taken any testosterone medication in the last 6 months?
Yes
No
If so, which one(s):
Medication 1
Medication 2
Medication 3
Do you have any history of prostate cancer?
Yes
No
What is your address?
ZIP / Postal Code
When is a convenient time for us to call you to schedule your screening?
What is your date of birth? (month/day/year)
Select preferred location to visit
*
Pompano Beach
Boynton Beach
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