Harmony2Health Peptide Intake

Health to Harmony Med Spa

Patient Intake Questionnaire
Name*

First NameLast Name
Age*
e.g., 23
Date Of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
Instagram/TikTok Influencer Promo Code
Current Health Status*

Height

Weight
Are you diabetic?*

Type 1Type 2Not Diabetic
Hormone Therapy History*

I have done hormone therapy before.I have NOT done hormone therapy before.


Height
Weight

Important Health Questions*

	Yes	No
Do you smoke?
Do you drink alcohol?
Are you taking any harmful substances?
Are you on a special diet?
Do you have any allergies?

Thyroid (check all that are troublesome)*

	Yes	No
Heat Intolerance
Heart Palpitations
Insomnia
Infertility
Constipation
Hair Loss
Muscle Cramps
Hoarse Voice

If you answered yes to any of the questions above, please explain:
Do you or anyone in your family have a history of:

Multiple Endocrine Neoplasma Type II (MEN)Renal StonesPancreatitisGastroparesisSmall Bowel Obstruction
Are you currently taking any medications (supplements, vitamins, contraceptives, etc.)? If yes, please list them below and the reason why you're taking it.*
Have you undergone any surgery in the past? If yes, please indicate the name of the procedure.*
What is your goal in taking Semaglutide/Peptides?*
Family History: Please select if your family has a history of any of the conditions listed below:

AsthmaHeart DiseaseProstate CancerHypertensionDiabetesBreast CancerOvarian CancerMental IllnessOther
Semaglutide Protocol (Weekly Shot) - Sample

Week 1-3 - Dosage of .125 or 12.5 units

Consultation, pt sets up to discuss use if experience side effects.

Week 4-6 - Dosage of .20 or 20 units

Consultation, pt sets up to discuss use if experience side effects.

Week 7-9 - Dosage of .50 or 50 units

Consultation, pt sets up to discuss use if experience side effects.

Week 10-12 - Dosage of .65 or 65 units

Consultation, pt sets up to discuss use if experience side effects.

Week 13-16 - Dosage of .85 or 85 units

Consultation, pt sets up to discuss use if experience side effects.

Week 17-20 - Dosage of 1.0 or 100 units

*When 70% of GOAL weight is lost, begin to reverse ramp down off the medication and transition to other peptides.
By subscribing, you are enrolling in a monthly plan with a minimum commitment of six months. Monthly charges will occur on the anniversary of your initial sign-up date. Please be aware that billing will only commence once your paperwork has been reviewed and approved by our medical staff.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a copy of your bloodwork? If yes, please upload the file in the following section.*

YesNo
Blood Work

Cancelof
Driver's License*

Cancelof
Signature*

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Print Name*

First NameLast Name
Date*

MonthDayYear
Date
The goal of this consent form is to review the potential risks and benefits associated with the use of hormone/peptide therapy.

A. The full medical effects and safety of hormone therapy are not fully known.

Potential adverse effects may include, but are not limited to:

Constipation, Diarrhea, Nausea, Abdominal Pain, Thyroid Issues, Dizziness, Pancreatitis, Sweating and Elevated Heart Rate.

B. The risks for some of the above adverse events may be INCREASED by

Pre-existing medical conditions
Pre-existing psychiatric conditions
Cigarette smoking
Alcohol use

My signature below constitutes my acknowledgment of the following:

I have read and understood the above information regarding hormone/peptide therapy, and accept the risks involved.

I believe I have adequate knowledge on which to base an informed consent to the provision of hormone/peptide therapy I authorize and give my informed consent to the provision of hormone/peptide therapy.

It is therefore expressly agreed that I am voluntarily participating in this
program and all bioidentical hormonal replacement regimens, and the use of any medications and/or supplements is undertaken at my own risk.

I am voluntarily participating in this program and assume all the risks of injury to myself that might result. I hereby agree to waive any claims or rights I might otherwise have to pursue legal remedies from Harmony2Health, its staff, or treating providers for injury to myself on account of involvement in the Bioidentical Hormone/Peptide Replacement Program.

I have carefully read this waiver and fully understand that it is a release of
liability.

I accept all terms and conditions of this program.
Signature

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Gender*

MaleFemaleOther
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Health to Harmony Med Spa