PLEASE COMPLETE THE INFORMATION IN THE BOXES BELOW:

PHYSICIAN NAME AND ADDRESS

LAST NAME	_____________________
FIRST NAME	_____________________
INITIAL	_____________________
COMPANY	_____________________
ADDRESS1	_____________________
ADDRESS1	_____________________
CITY	_____________________
STATE	_____________________
ZIPCODE	_____________________
PHONE NUMBER	_____________________
FAX NUMBER	_____________________
EMAIL	_____________________
MEDICAL LICENSE (STATE?)	_____________________
LICENSE NUMBER	_____________________
EXPIRES	_____________________
DEA NUMBER	_____________________
EXPIRES	_____________________
ANY FELONY CONVICTIONS (YES/NO)	_____________________
ANY STATE LICENSING ISSUES {YES/NO)	_____________________
ACTIVE HOSPITAL PRIVILEGES (YES/NO)	_____________________

I, _______________________________, residing at (address)_________________________
_________________________________ request to participate in the research protocol entitled "Treatment of Men with Adult Onset Diabetes with Testosterone." By signing below, I certify that I am a duly licensed physician in the state of ________________. I have no felony convictions and am in good standing with my hospital, local and state medical boards. I have an unrestricted DEA license to order testosterone. And, if given an authorization number and protocol to continue, I will follow the instructions of the research study and notify Dr. Lichten in writing of any complications or difficulty with this study.

_________________________________(signature)

_________________________________(witness signature)

____________________(date)

TO PARTICIPATE IN THE Men's TESTOSTERONE in DIABETES STUDY!
• PART I: Read through the following Introduction and Selection Process
• PART II: Print out the History, Physical and Screening laboratory tests for your physician to complete.
• PART III: Have your physician complete the REQUEST TO PARTICIPATE
• PART IV: Sign the informed consent, have your doctor witness it, and mail MEDICAL HISTORY and physical exam (including prostate), PARTS II, III, and IV back to me. Fax questions to me at (248)358-2513.
• PART V: I will mail back an authorization number for this individual at this doctor location only.

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