Myndfl Form

Complete the Form below for the Myndfl Weight Loss Program, and we will contact you to get started.
Program Overview
Participation in a weekly support group on Saturday afternoons at our office in Northbrook is required for this program. If you have insurance, some of the program will be covered. All patients are required to complete a virtual consultation with our Myndfl Medical Director prior to participation.If you are medically cleared for Peptide Therapay, you will meet with a Myndfl Clinical Therapist for a virtual intake session.
Today's Date*

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Date
Name*

First NameLast Name
Weight (Estimate)Number*
Height (Estimate)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Employer*
Occupation*
MarriedPartneredSingle
FemaleMaleNon-Binary
How did you hear about us?*
What goals are you seeking to achieve through Peptide Therapy?*
What will it mean to you to reach your weight loss goals?*
YesNo
If you have tried peptide therapy before, tell us about your experience.
InsuranceOut-of-PocketUnsure
If using insurance, what insurance plan and type?
If using insurance, does it include mental health and registered dietician coverage?
Health Information Questionnaire
Health Information Questionnaire
Please list any and all NON-MEDICATION ALLERGIES: (Ex: pollen, food, pets, mold) (Write “none” if you don’t have any)
Please list any and all MEDICATIONS you are currently using WITH DOSAGE(S) (Write “none” if you don’t have any)
Please list any and all SUPPLEMENTS (ex: vitamins, herbs) you are currently using WITH DOSAGE(S) (Write “none” if you don’t have any)
Please list any and all CHRONIC MEDICAL OR PSYCHIATRIC HISTORY with DATE OF ONSET: (Write “none” if you don’t have any)
How often do you EXERCISE? (Aerobic and/or resistance?) *
Describe your diet: (Balanced? Fast food?)*
Do you participate in mindfulness activities? (Yoga, meditation, etc.)*
Do you use tobacco? (How much? How long? Type?)*
Do you use street drugs? (What kinds? How often?)*
Rate your current ENERGY LEVELS (scale of 1-10)*
Rate your current QUALITY OF SLEEP (scale of 1-10) *
Rate your current PHYSICAL PERFORMANCE (scale of 1-10)*
Rate your current OVERALL FITNESS LEVEL (scale of 1-10) *
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
AnxietyDepressionAlcoholismHigh Blood PressureDiabetesThyroid DiseaseHeart Attack or DiseaseHigh CholesterolStrokeCancerOtherNone
Informed Consent
By signing below, you confirm that you have read and agree to the
policies presented above.
Today's Date*

MonthDayYear
Date
I am executing this consent to confirm my decision to purchase peptides and to verify my understanding of the risks and alternatives to treatment with peptide therapy.
The goals and possible benefits of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial, and unnecessary by the Food and Drug Administration (FDA).

Risks:
At prescribed doses, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy.
Some adverse reactions may include but are not limited to injection site redness, flushing, transient high blood sugar, development of antibodies peptides, and water retention. These side effects are dose-related and usually eliminated by adjusting the dosage. This drug should not be used in patients with known cancer or are pregnant.

By signing this form, I understand the possible risks associated with this treatment.
I understand that Myndfl cannot guarantee that I will not experience any side effects or adverse reactions.

I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy.

I certify that I have read the foregoing Informed Consent, discussed the issues noted above, had
opportunities to ask questions and agree and accept all of the terms above.
Signature

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Complete the Form below for the Myndfl Weight Loss Program, and we will contact you to get started.

Program Overview

Health Information Questionnaire

Informed Consent