PureEHR - Patient Details

First Name *

Last Name *

Phone *

Email *

DOB *

Sex *

Male

Female

Other

How did you hear about us? *

Facebook

Instagram

Website

YouTube

Other

Promo Code

Apply

Height *

Feet

Inches

Weight *

Lbs

Home Address

Street *

Unit / Suite / Apartment

Zipcode *

State *

City *

Upload a picture of the front of your Drivers License or Government Issued I.D. Only JPG,JPEG,PNG and PDF formats. | Maximum file size allowed is 10MB

Home address on your Drivers License the same as your mailing address *

Yes

Mailing address same as home address *

Yes

Mailing address

Street *

Unit / Suite / Apartment

Zip *

State *

City *

Do you have health insurance? *

Yes

We will send you for blood work. Please indicate which lab works with your insurance. *

LabCorp

Quest

Other

Please confirm with your insurance which lab is preferred under your coverage and be aware your deductible and coinsurance may apply.

Local Pharmacy Information

Name

Phone

Before we send you for Bloodwork, we would like to learn more. Please indicate what some of your Challenges and Goals are.

Decrease in *

Muscle Mass

Strength

Endurance

Stamina

Sex Drive

Menstrual Cycles

Menstrual Regularity

Ability to Have Orgasms

Other

Increase in *

Body Fat

Feeling Tired

Inability to Sleep

Brain Fog

Thinning Hair

Mood Swings

Other

Worsening *

Memory

Fatigue

Hot Flashes

Night Sweats

Irritability

Joint Pain and/or Stiffness

Erectile Dysfunction

Painful Intercourse

Other

How Long have symptoms occurred? *

0-6 Months

6-12 Months

12 Months or more

How would you rate symptom severity? *

Mild

Moderate

Severe

Is there anything else you would like to share with us?

Click here to upload additional document.

In addition, please use the following link to verify your credit card in the amount of $1.00, to hold your appointment for your lab review, with Dr. Suarez. CLICK HERE

Please note this is a secure site to protect patient confidentiality.

Home Address

Mailing address