Men's Free Testosterone Testing Request

Once the form is completed, someone from Renewed Medical will reach out to you within 24-48 hours to schedule your Free Testosterone Testing.

Men's Free Testosterone Testing Request Form

Name*

First

Last-name

Last

Age*

Phone*

Email*

Address*

Street Address

*

Address Line 2

*

City

State

*

ZIP Code

Date of Birth*

GenderMaleFemale

What is your height?*

What is your weight?*

How did you hear about us?*Friend/Family MemberRadioInternet SearchSocial MediaOther

Friend or family member name*

What Radio Station?*

What were you searching for on the internet?*

What social media site/app did you see us on?*

What other source did you find Your Wellness Center*

Hormone Information

Hormone Imbalance Checklist*Aches and painsAnxietyApathyAutoimmune IllnessBlood sugar imbalanceBone lossBurned‐out feelingChronic IllnessCold body temperatureDecreased libidoDecreased mental sharpnessDecreased muscle massDecreased staminaDecreased urine flowDepressionElevated cholesterolElevated triglyceridesErectile dysfunctionEvening FatigueFibromyalgiaFoggy thinkingGeneral FatigueHeadachesInability to lose weightIncreased urinary urgeIrritabilityLack of motivationMorning FatigueNight SweatsOily SkinProstate problemsSleep disturbancesSusceptible to infectionsWeight gainOther (list below)NONE OF THE ABOVE

I consent to receive testing results via e-mail from Renewed Medical Staff to the address provided above.*I agree

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TUCSON

2825 E. Broadway Blvd
Tucson, AZ 85716

(520) 298-0005 phone
(520) 367-5771 fax

HOURS

M - F | 9am - 5pm
Sat | 10am - 4pm

GREEN VALLEY

514 E. White House Canyon Rd
Green Valley, AZ 85614

(520) 777-7831 phone
(520) 777-7832 fax

HOURS

M | 9am - 5pm
Th | 10am - 4pm

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