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For your free Testosterone Replacement Therapy (TRT) or Hormone Replacement Therapy (HRT) blood requisition

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Privacy and Consent

I acknowledge and agree to the Terms & Conditions provided by the company. I understand that any information I provide, including my contact details, is considered private patient information and will be handled confidentially in accordance with applicable privacy laws. By providing my phone number, I consent to receive secure text communications regarding my care, treatment, and services related to this inquiry.

First Name *

Last Name *

Phone *

Email *

Date of birth *

Service *

Hormone Replacement Therapy (H.R.T) *For Women*

Testosterone Replacement Therapy (T.R.T) * For Men*

Why do we need this?

Your information will be used to securely contact you about your eligibility, provide personalized treatment options, schedule appointments, and ensure continuity of care. All information you provide is treated as private patient data and handled in accordance with applicable healthcare privacy standards.

Address

Street Address *

City *

State *

Country *

Postal code *

Why do we need this?

We use your address to generate and send your blood requisition to the nearest partnered lab and to facilitate any required testing. Your information is securely stored and treated as confidential medical data under applicable privacy laws.

OHIP Colection *

I agree and understand that providing my OHIP number is essential for insured medical services, including lab work. I acknowledge that by choosing not to provide my OHIP number, I may be responsible for covering the cost of certain services out-of-pocket and may experience delays in receiving care. My information will be handled with the highest standards of privacy and in accordance with all applicable healthcare regulations

Select an option *

I don't have OHIP

I prefer giving it to a human (I consent to being contacted about my OHIP)

I consent to providing my OHIP (collected on the next page)

Why do we need this?

As a registered medical facility in Ontario, we require your OHIP number before your appointment. This helps us confirm your eligibility for insured lab work and covered medical services, reduce out-of-pocket costs, and streamline your care through the public healthcare system.

OHIP Number (including letters)

By providing your OHIP number, you consent to its use for verifying your healthcare coverage, generating lab requisitions, and facilitating access to medically necessary services. This information will be securely stored and treated as confidential patient data in accordance with all applicable privacy laws and healthcare regulations.