Peptide Intake Form
Stage 1 Intake From
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your current height and weight and what treatment are you interested in ? Please also share your goal weight
Have you been diagnosed with an eating disorder?
yes
no
Are you currently?
Pregnant
Breastfeeing
Planning to become pregnant
none of the above
Do you use recreational drugs?
yes
no
Do you have a fasting triglyceride level above 500?
yes
no
Are you on Warfarin?
yes
no
Do you have a family history of Thyroid Cancer?
yes
no
Do you have a history of gallbladder disease?
yes
no
Do you have a history of multiple endocrine neoplasia?
yes
no
Do you have a history of pancreatitis?
yes
no
Have you had bariatric surgery in the last 12 months?
yes
no
Have you been diagnosed with ?
Type 1 Diabetes
Type 2 Diabetes
No
Are you currently on a medical weight loss program?
*
What medication are your requesting?
*
WHO REFERRED YOU HERE ?
*
You will receive a text message to schedule a consult to go over this form prior to your provider consult. I consent to text messages from Vivara Wellness.
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