Men's Midlife Health and Testosterone Self-Referral Form

$295

45-60 minute virtual visit

THE CONSULTATION

Men's Midlife Testosterone Deficiency and Health Assessment as supported by Harvard Medical, Current Guidelines, and/or Evidence and Literature:

Bloodwork to rule out other causes of your symptoms and assess pertinent disease risk (includes checking Testosterone Levels)

Assessment of your lifestyle, health profile, family history, and midlife experience

Discussion about all of your treatment options: lifestyle, therapies, supplements and hormonal

Prescriptions (if that’s what we decide) to treat your bothersome symptoms and optimize health: non-hormonal and hormonal including Testosterone Therapy (TTh) and other medications if indicated and safe

The Midlife Health Review to discuss your risks for disease and decline, and how you can prolong your health and independence through lifestyle modifications, supplements, and medications

Visit Care Plan Summary: a written summary will be provided to you including what you're already doing well, what you can work on, medications we started and why, helpful resources, and next steps

$125

30 minute phone visit

THE FOLLOW-UP

Judy will see you in follow-up to ensure that your plan of care and prescription therapy is going well.

Reassessment: if we start any medications, we follow-up to ensure they are working and without bothersome side effects, and make any necessary adjustments. We will also follow-up on the non-prescription recommendations to see how you're doing and if you have any questions. (Note that more than one follow-up may be required if we adjust medications)

Bi-Annual Visits once you are on Hormone Therapy with stable levels and effective results, we will check in every six months to ensure benefit still outweighs risk and to update prescriptions.

NEXT STEPS

If you would like to proceed with seeing Judy:

1.Complete and submit the form below. Please allow 2-3 weeks for Judy to review your information and follow-up with you via phone or email.

2. Once you have paid for the assessment, your care will begin. You’ll receive forms, a lab requisition, and instructions to collect other information.

3. When Judy has received all of the pertinent information, your virtual consultation will be scheduled.

4. For the consultation, you simply log in and we will have our visit, initiate therapy if indicated, and schedule our follow-up .

PRIVATE PRACTICE

MEN’S TESTOSTERONE AND MIDLIFE HEALTH ASSESSMENT SELF-REFERRAL FORM

MEN'S HEALTH SELF-REFERRAL FORM

First Name

Last Name

Eligibility Criteria

Please note that Judy does NOT prescribe HCG.

Male of Ontario residence over 35 years old with no prior history of prostate or breast cancer and no longer wishing to maintain fertility

Male of Ontario residence over 35 years old already on prescription therapy and seeking a new provider or review of current therapy

Mobile Phone Number

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Health Card Number and Version Code

The version code is the two letters at the end of the Health Card Number

When did your symptoms start?

If you can't recall exactly when, try to approximate the month and year.

YYYY

How can Judy help with your transition?

This helps Judy ensure that the care she provides aligns with the care you are looking for. (i.e. understand my symptoms and treatment options, menopause hormone therapy discussion, not interested in hormone but seeking counselling are some examples of reasons we collaborate with/care for patients).

Visit Coverage

I live outside of Huron-Perth and understand that this is a private practice

I agree to the private practice fees as detailed on Judy's website.

Primary Care Team Information

MD/NP Name, Address, and is Fax Number Required

Anything else you'd like to share

THE CONSULTATION

THE FOLLOW-UP

NEXT STEPS

PRIVATE PRACTICE

MEN’S TESTOSTERONE AND MIDLIFE HEALTH ASSESSMENT SELF-REFERRAL FORM

Judy Gardiner