PURE Wellness Program Intake Form

1

Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

3

Email* This field is required.

example@example.com

4

Phone Number* This field is required.

Please enter a valid phone number.

5

Height & Weight

6

Do you have any Medical Problems?* This field is required.

YESNO

7

If you have Medical Problems. Please share Details* This field is required.

8

Do you have any allergies?* This field is required.

YESNO

9

If you have Allergies. Please share Details* This field is required.

10

Have you had any surgeries?* This field is required.

YESNO

11

Please share details of Surgery* This field is required.

12

Are you currently on any Prescription Medications?* This field is required.

YESNO

13

Please share list of Medicines* This field is required.

14

Important Health Disclosures* This field is required.Please check all that apply

Has anyone in your family had Pancreatitis?

Has anyone in your family had Medullary Thyroid Cancer?

Are you currently pregnant, nursing, or planning to become pregnant?

None of the Above

15

How would you rate your current energy levels?* This field is required.

Low

Moderate

High

16

How would you rate your current sleep quality?* This field is required.

Poor

Fair

Good

Excellent

17

Do you Exercise Regularly?* This field is required.

Yes

No

18

Consent* This field is required.

I understand that peptide therapies may not be FDA-approved for all uses and are provided under medical supervision.

I consent to a consultation to determine my eligibility for the Peptide Program.

19

Please Sign* This field is required.

Clear