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Total Rejuvenation Center
Intake Form

Birthday
Month
Day
Year
Which treatment(s) interests you?
What are your top goals?
Do you experience any of the following symptoms?
Current Regimen:
Do you have trouble maintaining an erection?
Yes
No
Have you noticed hair loss?
Yes
No
Do you have a decrease in your libido?
Yes
No

We use this information to better assess which medications are right for you.

We use this information to better assess which medications are right for you.

Have you ever had any of the following condition(s)?
Were you diagnosed with bulimia nervosa or anorexia nervosa in the last year?
Yes
No
Do you have a history of drug or alcohol abuse?
Yes
No
Does anyone in your immediate family have a history of any of the below?
How did you hear about us?
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