Payment Form – Age Well Meds

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Testosterone Therapy
B12 Injections
Enclomiphene

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DMRX BY AGE WELL INTAKE

Step 1 of 12

8%

Please Select Your State To Get Started(Required)

TRT Therapy(Required)

$250.00-(2.5 Month Supply @ $99/month)

N/A

Includes Initial Consult, TestosteroneCypionate, Syringes and *Anastrazole If Needed

Sermorelin Growth Hormone Peptide Therapy(Required)

$777.00 - (3 Month Supply @ $259/month)

N/A

Includes Initial Consult, Sermorelin, and Syringes

B12 Therapy(Required)

$125.00 - (2.5 Month Supply)

N/A

Includes Initial Consult, B12, and Syringes

Enclomiphene(Required)

$375.00 - (3 Month Supply @ $125/Month)

N/A

Includes Initial Consult and Enclomiphene

Shipping(Required)

Total

Bloodwork for Testosterone Replacement Therapy(Required)

$129.00 - Includes Total Test, CBC, CMP and PSA*

I have my own labs which I will upload. (Must Include Total Test, CBC, CMP) (*Must also include PSA if older than 40)

N/A

Using your own lab test.

Read carefully. You may use your own lab work if it meets the following criteria: Labs must include Total Testosterone, LH, & SHBG (or Free Testosterone). Must have been collected within the last six months. You will be asked to use the same lab vendor and panel for your follow-up lab test (completed about 30 days after starting treatment, or as required by your licensed Maximus doctor).

Sample Collection Date

MM slash DD slash YYYY

Total Testosterone(Required)

Optional

Luteinizing Hormone (LH)

Free Testosterone (Required if SHBG not provided)

ng/dL

pg/mL

Free Testosterone (Required if SHBG not provided)

Sex Hormone Binding Globulin (SHBG)

Estradiol (E2) (Optional)

Prolactin (Optional)

Hematocrit (Optional)

Alanine Aminotransferase (ALT) (Optional)

Prostate-Specific Antigen (PSA) Optional

Follicular Stimulating Hormone (FSH) (Optional)

Gamma-Glutamyl Transferase (GGT) (Optional)

By uploading your results, you attest your baseline lab work meets the criteria outlined above, and agree to use the same lab vendor and panel for follow-up testing. A member of the clinical team will review your lab work within 2 business days to ensure lab criteria are met

Max. file size: 1 GB.

How did you hear about us?

Total

Name(Required)

First Last

Gender

Email(Required)

Phone(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Patients under 24 not eligible for treatment

Would you be willing to Opt-in for SMS/Text Message notifications with important updates such as prescription expiration reminders, latest offer and treatments, updates from your healthcare provider, shipping and order updates and lab results, if applicable?(Required)

Yes

No

Total

Do you have any allergies or sensitivities to any of the following?

None that I am aware of

Clomid / Clomiphene Citrate / Enclomiphene Citrate

Vitamin D

Vitamin K

Any food, dyes, medicines, herbs, vitamins, or supplements not listed above (please specify)

Let us know here...

Do you take any medications, vitamins, or supplements regularly?

Yes

No

Are you taking any of the following medications or supplements?

Testosterone Replacement Therapy

Anabolic Steroids or SARMs

Clomid / Clomiphene Citrate / Enclomiphene Citrate

Tamoxifen

Other SERMs

Aromatase inhibitors

OTC Herbal or Non-herbal Testosterone Boosters

Blood Thinners / Anticoagulants

Vitamin D

Antiplatelets

Erectile Dysfunction Medications

Proscar / Propecia / Finasteride or Avodart / Dutasteride

Nitrates

Blood Pressure Medications

None

How much Vitamin D do you take per day (on average)?

Less than 1,000 IU

1,000 to 2,999 IU

3,000 to 4,999 IU

5,000 to 9,999 IU

10,000 IU or more

I’m not sure

Please list any current medicines, vitamins, or dietary supplements you take regularly, including the dosage and reason.

Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 4 weeks, even if you are not taking them daily.

Select the conditions that you currently have or have ever been diagnosed with

Prostate Cancer

Pituitary Adenoma / Hyperprolactinemia

Male Pattern Baldness / Receding Hairline

Enlarged Prostate / Benign Prostatic Hyperplasia (BPH)

Erythrocytosis (or hematocrit levels greater than or equal to 52%)

Obstructive Sleep Apnea

Adult Acne

Mania

Bipolar Disorder

Liver Disease

Kidney Disease

Uncontrolled thyroid or adrenal dysfunction

Organic Intracranial Lesion

Vitamin D Deficiency

Coagulopathy / Bleeding or Clotting Disorder

Malabsorption Conditions

Severe Lower Urinary Tract Symptoms

None

Other (please list)

Please let us know here...

Select the conditions that your immediate family have or have ever been diagnosed with

Prostate Cancer

Pituitary Adenoma / Hyperprolactinemia

Male Pattern Baldness / Receding Hairline

Enlarged Prostate / Benign Prostatic Hyperplasia (BPH)

Erythrocytosis (or hematocrit levels greater than or equal to 52%)

Obstructive Sleep Apnea

Adult Acne

Mania

Bipolar Disorder

Liver Disease

Kidney Disease

Uncontrolled thyroid or adrenal dysfunction

Organic Intracranial Lesion

Vitamin D Deficiency

Coagulopathy / Bleeding or Clotting Disorder

Malabsorption Conditions

Severe Lower Urinary Tract Symptoms

None

Other (please list)

Please let us know here...

What is your height?

What is your weight? (in pounds)

What are your personal health goals with the Testosterone Protocol? (i.e. increased energy, stamina, sexual interest/performance, lean muscle gains, weight loss, sleep quality)

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Billing Address(Required)

Same as Shipping Address

Street Address Address Line 2 City State ZIP Code

Billing address used for credit card authorization only.

Total

*If during your consultation you and the Dr decide treatment is not for you at that time, you will receive a full refund of your purchased hormone replacement therapy plan. Once our doctor approves your treatment we will give you a call to do your payment.

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DIRECT MEDS Rx

Our mission is to deliver exceptional healthcare by providing patients with access to quality prescription medications, all without the inconvenience of a traditional doctor’s office visit.

Contact Information

info@directmedsrx.com
954-886-8889
1100 Park Central Blvd S Suite 3600-C Pompano Beach, FL 33064

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DIRECT MEDS Rx

DMRX BY AGE WELL INTAKE

Using your own lab test.

Optional

DIRECT MEDS Rx

Our mission is to deliver exceptional healthcare by providing patients with access to quality prescription medications, all without the inconvenience of a traditional doctor’s office visit.

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