Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Preferred Phone * (###) ### #### Preferred Email * Preferred Method of Communication * Text Message Phone Call Email Which programs are of interest to you? * Weight Loss (Semaglutide and Tirzepatide: Prices start as low as $575 per order depending on dose and location.) Hormone Optimization/Testosterone Therapy Men's Sexual Health Height Weight Biologic Gender Male Female I understand and attest I am not currently pregnant and understand if I become pregnant I agree to immediately stop therapy. I agree to stop therapy two months prior to attempting to become pregnant Do you have a history of Multiple Endocrine Neoplasia Type 2 (MEN-2),Medullary Thyroid Cancer, or Pancreatitis? Yes No Please clarify which one: Do you take any insulin or sulfonylurea medications (ie Glimepiride)? Yes No Please specify which medications: How did you hear about us?/Who referred you? * Please mention the person who referred you by name as RPM strives to match each new patient with the same provider who gave great care to the person who referred you. RPM also tries to thank individuals who help grow the practice by often offering “Thank you” referral discounts on their own order. If someone has referred you, please mention them by name so we can direct you to the same great provider and that referring person can receive their “thank you” discount. Do you have a provider preference? If so, who? Additional Comments: Promo Code * Must be check prior to allowing submission of the form. I understand that Revive Performance Medicine is a concierge based practice and does not accept insurance. * I attest that I am located in a state that RPM provides services, PA, OH, FLA, GA. Thank you! Request AppointmentRequests are usually addressed within 24 hours.
