FORM – Self-disclosure for hormone treatment, man

Please take the time to answer the following questions and send us the form in good time – preferably five days before your appointment with us at the latest. Then your doctor can personally prepare for your visit.

Of course, it is not a problem if you are unable to answer all the questions. Please fill in these fields with a question mark (?). We use your data exclusively for treatment and we will not pass them on to third parties. The form is encrypted before being sent via the Internet.


The items and fields marked with * are mandatory.
This is not a valid Date.


This is not a valid Date.
This is not a valid Date.
Security code Reload
This is not a valid Date.
Please fill in all marked fields correctly.
Thank you for filling out the form, it has been successfully transferred. We will contact you shortly.


Consultations can be booked via:
Telephone: +49 (0) 69 5060 6865-0

Back to overview Getting here