WELCOME TO BODY LABS!
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Name
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Phone Number
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Email
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What Telemedicine services interest you? *All treatments are shipped to your door
Medical Weight Loss
Men/Women's Hormones (TRT/BHRT)
Peptide Body Optimization
Prescription Skin Care
In Depth Lab Testing
Vitamin Injections
BCAA's/Nootropics/Nutraceuticals
Research Peptides- Not Affiliated w/Medical Providers
Nutrition Counseling
Diet Plans and Grocery Lists
Sexual Health for Men and Women
Other
Do you consent to communication from our Care Coordinators?
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Transitioning
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Address
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What is your current weight and height?
You may skip if not interested in weightloss
Tell us about your diet in two brief sentences.
What area would you like to focus on first and foremost?
What food choices do you struggle with the most?
Do you exercise?
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PAYMENT INFORMATION
What are your goals and an ideal time frame to reach them?
Yes? Explain briefly
Which symptoms would you like to improve?
Overall drive
Symptoms of depression
Difficulty sleeping
Hot flashes
Loss of concentration, sociability, and activity
Loss of interest in sex
Decreased desire and ability to exercise
Decreased energy and endurance
Decreased sense of well-being
Decreasing memory
Decreasing muscle strength
Sagging, loose or thin skin
Sore Muscles, joint pain(s)
Weight loss - Unexplained
Reduced erectile function
Pale Skin, We can tan you with Melanotan Peptide!
Feeling very tired all the time (fatigue)
Obesity
Stomach pain
Irritable bowels
Intense sugar cravings
Are you interested in peptides (BCAA's) for any of the life improving therapies listed below?
Growth Hormone Stimulator
Hormone Enhancement
Cardiovascular health
Metabolic boost
Age Rewind
Weightloss Peptides
Complete Pro Performance Peptide Blend
Have you had your labs done in the past 3 months?
Yes, I can send in my lab results
No, but I am interested in checking my levels
Only here for the weightloss with no labs
Curious about pricing and type of testing offered
What form of lab testing do you prefer?
Blood draw as a walk in to Quest or Labcorp $150+
Saliva testing kit shipped to you? $220
Blood Spot test shipped to you? $200
Concierge Blood draw from home/work? ($50 nurse travel fee state wide.) $200+
Hormone levels are all we require. As an added benefit, we have full lab testing capabilities at clinic cost available for all bodily systems.
Choose your preferred form of payment
Invoiced Cash/Self pay (discounted clinic pricing)
Monthly Auto PAy
FSA/HSA account
CARE credit
Affirm or Financing
Would you like to apply for low income pricing?
Do you consent to telehealth treatment and virtual services?
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No
Do you have any known allergies? If yes, then please specify below.
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List your medications below.
Medications I am taking
Are you currently taking medications? If yes, then please list the medications and the reasons
Have you been diagnosed with any of the following?
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Pancreatitis
Hypoglycemia
Thyroid Cancer
Do you have any communicable diseases, cardiovascular problems, diabetes, asthma etc.?
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Do you have labs to share with us from your PCP?
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How did you hear about us?
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Who referred you?
First and Last Name
Be Well Body Labs Acknowledgment, Authorization and Waiver for services
I voluntarily consent to receive telehealth services from Be Well Body Labs for the purpose of testosterone replacement therapy, weight loss, peptides and overall wellness. I give consent to Be well Body Labs to work with their preferred pharmacy to compound or fill my medication and authorize them to pick up and ship my RX to my home, understanding that it will not be tampered with. I understand that telehealth involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.I have read and understand the information provided regarding telehealth, have discussed it with my provider or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telehealth in my medical care.I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I understand that there are potential risks and benefits associated with any form of medical treatment, and that despite my efforts and the efforts of my provider, my condition may not improve, and in some cases may even get worse. I understand that I may benefit from telehealth, but that results cannot be guaranteed or assured. I understand that I have the right to access my medical information and copies of medical records in accordance with applicable laws. I understand that I am responsible for providing the necessary equipment and internet access for my telehealth sessions, securing the equipment on my side of the transmission, and arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for my telehealth session. I understand that there are alternatives to receiving telehealth services, such as in-person services. I understand that I have the right to choose among these alternatives and that I can change my mind at any time. By signing this form, I certify:- That I have read or had this form read and/or had this form explained to me- That I fully understand its contents including the risks and benefits of the procedure(s).- That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction. Be Well Wellness Services LLC, The Body Labs, AND ITS PHYSICIANS follow all state and federal guidelines. We do not illegally treat professional athletes. We do not treat those who are currently in any branch of military service (active duty or reservist) or those who anticipate entering the military while taking any therapeutic program which may be prescribed for you.You must have a verified deficiency and medical need to qualify for treatment by our physicians. The information and services provided by BodyLabsMD are designed to offer personalized, elective treatments that prioritize patient-centered care. While our protocols and treatments are based on the latest clinical evidence, they are not intended to replace traditional medical advice or treatment. We work in collaboration with licensed medical professionals to ensure all decisions are guided by clinical expertise. BodyLabsMD is committed to maintaining the highest standards of regulatory compliance, quality assurance, and ethical practice. Patients should consult with their healthcare provider before starting any new treatment.
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