Men’s Testosterone Therapy Screening Form Men's Testosterone and Midlife Virtual Health Clinic Referral Form * First Name Last Name Eligibility Criteria * Please note that Judy does 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 Email * Mobile Phone Number * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Health Card Number and Version Code * Visit Coverage I agree to the private practice fees details on Judy's website. Is there anything else you'd like to add? * Thank you for submitting your form. Next step: Please allow us 1-2 weeks to review your submission. Next you’ll receive an invoice from Judy’s Electronic Medical Records system.
