Full Peptide Intake Form

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Product SelectionYOU WILL NOT BE CHARGED AT THIS TIME. A clinician will review your intake questionnaire and, if you qualify, your peptide(s) will be shipped to you. If additional information is needed, a member of our team will reach out to you first.
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ORDER SUMMARY
Total costUSD
Skin Rejuvenation: Topical GHK-Cu May drive new collagen and elastin growth leading to healthier, vibrant and youthful skin
$250.00Edit
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Muscle and Metabolism: Sermorelin SQIncreases release of growth hormone which may help gain muscle mass and accelerate metabolism (Subcutaneous Injection)
$325.00Edit
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Muscle and Metabolism: Sermorelin Dissolving TrochesIncreases release of growth hormone which may help gain muscle mass and accelerate metabolism
$350.00Edit
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True Sexual Health: PT-141 (Nasal Spray)Interacts with neurotransmitters in the brain to promote sexual arousal and response and may even increase sense of emotional connection with your partner
$275.00Edit
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No Pain, No Pain - Injury Recovery: BPC-157May accelerate and improve injury recovery by reducing inflammation and driving the development of new blood vessels in injured tissues. (Subcutaneous Injection)
$350.00Edit
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NAD+ Nasal SprayNAD+ nasal spray represents an excellent means of supplementing your NAD+ levels without the hassle of injections or IVs and still offers great bioavailability.
$275.00Edit
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Total cost $0.00
First Name
Last Name
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Email* This field is required.
example@example.com
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What is your Date of Birth?* This field is required.
Date
Month
Day
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What gender were you assigned at birth?* This field is required.
Please Select
Please Select
Female
Male
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Do you have any known allergies to peptides or proteins?* This field is required.
YESNO
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Do you have any allergies to nicotinamide, niacin, NAD+ or other NAD+ related compounds?
YESNO
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Do you have any chronic sinus issues, nasal polyps, or other nasal conditions?
YESNO
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Are you currently using and NAD+ supplements, nicotinamide ribosome (NR) or nicotinamide mononucleotide (NMN) products?
YESNO
9
Have you ever been diagnosed with cancer or do you currently have cancer?* This field is required.
YESNO
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Are you currently pregnant or breastfeeding, or trying to become pregnant?* This field is required.
YESNO
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Do you have any autoimmune disease(s)?* This field is required.
YESNO
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What autoimmune disease(s) do you have?
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Do you have any chronic liver or kidney disease?* This field is required.
YESNO
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Do you have any thyroid disorders or have you ever been diagnosed with hypothyroidism or hyperthyroidism?* This field is required.
YESNO
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Do you have any cardiovascular conditions (either now or a history of) or have a pacemaker?* This field is required.Ex: Heart Disease, Arrhythmia (A Fib, Tachycardia, V Tach), Heart Failure, Stroke, TIA (mini-stroke), Heart Attack, Peripheral Artery Disease, Cardiomyopathy, Hypertension (high blood pressure)
YESNO
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Do you have any history of hypertension (high blood pressure)?* This field is required.
YESNO
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Do you have any history of copper metabolism disorders (e.g., Wilson’s disease), scleroderma, or mixed connective tissue disease?* This field is required.
YESNO
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Are you currently taking any growth hormone medications or growth hormone secreting peptides?* This field is required.
YESNO
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Do you have any active infections at this time?* This field is required.
YESNO
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What infections do you have? Are you taking anything to treat them?
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Do you have diabetes, high sugar levels, or other metabolic disorders?* This field is required.
YESNO
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Do you have chronic gastrointestinal disease(s)?* This field is required.Example: ulcers, Crohn's disease, Ulcerative Colitis
YESNO
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What gastrointestinal disease(s) do you have?
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Do you have any other known allergies? * This field is required.
YESNO
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Please list your other allergies
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Do you have any history of dermatological conditions?* This field is required.Ex: eczema, psoriasis, tinea, etc.
YESNO
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What dermatological issues have you had or do you have now?
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What skin issues are you experiencing at this time?* This field is required.Ex: scars, wrinkles, dry skin, signs of aging, etc.
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Have you had previous dermatological treatments?* This field is required.
YESNO
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Please select all that apply* This field is required.
Botox
Dermal Fillers
Microneedling
Laser or Fractal Treatments
Cosmetic Surgery
Peptide Treatments
Other
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Do you have any medical or surgical history?* This field is required.
YESNO
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Please list your medical and/or surgical history
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Are you on any prescription medications or over the counter supplements?* This field is required.
YESNO
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Please list your medications and supplements
35
Are you currently suffering from any active pain or injury?* This field is required.
YESNO
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Please specify area of pain or injury, and the cause
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Do you smoke or use other tobacco products?* This field is required.
YESNO
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Please specify what you use and how much
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How many alcoholic drinks do you consume per week?* This field is required.On average
Please Select
Please Select
0
1-4
5-11
12-20
21+
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How would you rate your level of physical activity, weekly?* This field is required.'Sedentary' is none, 'Very Active' is 6+ days per week of 30min or more
Please Select
Please Select
Sedentary
Lightly Active
Moderately Active
Very Active
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We are sorry, but based on your information, you do not prequalify for your selected therapy.

That does not mean you are not a candidate - we need more information to decide first.

A member of our team will rech out to your shortly or you can call or email us at:

617-686-5614

info@aeonic.health
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Congratulations! You prequalify for the peptide(s) you selected.

Next, we will gather the rest of your information and present you with a consent form to read and sign.
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Name* This field is required.
First Name
Last Name
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Shipping Address* This field is required.
Street Address
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Phone Number* This field is required.
Please enter a valid phone number.
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MUST READ:

AEONIC HEALTH Peptide Therapy Informed Consent

General Information about Peptide Therapy:

Peptides are short chains of amino acids naturally occurring in the body, playing crucial roles in

various biological processes, including hormonal balance, immunity, and cognitive function.

Factors like aging, lifestyle choices, and poor diet can slow down peptide production, leading to faster aging, fat accumulation, lack of energy, and muscle mass decrease.

Administration Methods:

Peptides can be administered via subcutaneous injections, transdermal creams, nasal sprays, or oral tablets. Injections are generally minimally painful due to the small needle size.

Potential Benefits:

Depending on the peptide, potential benefits may include:

• Prevention and reduction of aging symptoms

• Hormonal balancing

• Immunity enhancement

• Assistance with weight loss or muscle gain

• Pain reduction

Peptides Offered by AEONIC HEALTH:

• CJC-1295/Ipamorelin

• Sermorelin

• GHK-Cu

• PT-141

• BPC-157

FDA Approval:

Most peptides provided by AEONIC HEALTH are not FDA-approved to treat, cure, or prevent any disease and are considered experimental. Sermorelin and PT-141 are FDA-approved for specific uses and are used off label by AEONIC HEALTH.

Potential Side Effects and Risks:

Peptides can have risks and side effects, including but not limited to:

• Temporary metabolic disturbances (e.g., changes in blood sugar, blood pressure)

• Development of antibodies to peptides• Fluid retention

• Alteration in lipid profiles

• Allergic reactions, including life-threatening allergies

• Discomfort at the injection site (e.g., pain, redness, swelling, infection)

• Injury to nerve and/or muscle at the injection site

Specific Peptide Risks:

• CJC-1295/Ipamorelin: Risks include immunogenicity, increased heart rate, and systemic vasodilatory reaction.

• GHK-Cu: Limited data on safety; risks include immunogenicity and peptide-related impurities.

• BPC-157: Risks include immunogenicity and limited safety-related information.

• PT-141 (Bremelanotide): Risks include increased blood pressure, darkening of the skin, and various injection site reactions.

• Sermorelin: Common side effects include pain, redness, or swelling at the injection site.

Contraindications to Peptide Therapy:

Peptide therapy is contraindicated during pregnancy and breastfeeding, and for individuals with a history of cancer or other specific medical conditions.

Available Alternatives to Peptide Therapy:

This is an elective treatment. Alternative therapies include bioidentical hormone replacement therapy, herbal therapies, supplements, lifestyle modifications and other medical treatments.

By signing this form, you acknowledge that you understand and agree to the following:

• No Guarantees: Results may vary, and there is no guarantee of symptom improvement.

• Following Instructions: It is crucial to follow dosing and administration instructions.

• Complete Medical Information: Disclose all personal medical information to ensure safe treatment.

Certification of Consent to Proceed with Treatment: By signing this informed consent form, you confirm and agree that you have read and understood the information provided, have had the opportunity to ask questions, and freely and voluntarily accept all risks associated with peptide therapy.
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I acknowledge that I have read and understood Aeonic Health Peptide Therapy Informed Consent* This field is required.
YESNO
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Attestation of Physical LocationI acknowledge and confirm that at the time I am completing this questionnaire, I am physically located in one of the following states: California (CA), Florida (FL), Massachusetts (MA), Vermont (VT), or Wyoming (WY). I understand that the services and consultations provided are subject to the laws and regulations of the state in which I am located, and that misrepresenting my physical location may disqualify me from receiving services or products. By checking this box, I certify that the above statement is true and accurate to the best of my knowledge. I understand that providing false information may result in the termination of services and could have legal implications.
I confirm that I am physically located in one of the listed states.
I do not confirm this statement and understand that I do not qualify for these services.
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I acknowledge that I have read and understood Aeonic Health Peptide Therapy Informed Consent. Additionally I acknowledge that all information provided in this form is accurate.I understand and accept responsibility for any missing or false information in this form and realize that it can put me at undue risk of side effects or harm from the peptides I am interested in using.
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