LAB REQUEST FORM

Name *

First Name

Last Name

Phone *

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Gender

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

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DD

YYYY

Medical ParQ

Please check all that apply

Low Sex Drive (Libido)

Erectile Dysfunction

Fatigue or Decreased Energy

Loss of Muscle Mass and Strength

Increased Body Fat

Mood Changes (depression, irritability, lack of motivation, etc.)

Reduced Testicle Size or Changes in Firmness

Decreased Bone Density

Difficulty Concentrating or Memory Problems ("Brain Fog")

Changes in Appetite

HIPAA Consent for Communication *

By checking this box, I consent to receive communications from Tytin Wellness via text and email. I understand that these methods are not secure and may risk unauthorized access to my protected health information (PHI). I acknowledge that Tytin Wellness is not liable for any unauthorized access resulting from these communications. I am aware of my rights under HIPAA regarding my PHI and can withdraw my consent at any time by notifying Tytin Wellness.