enhancepsych.com - Peptide Intake Form

Patient Information
Patient Name

First NameMiddle NameLast Name
Occupation
Date of Birth

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Date
Height (feet/inches)
Weight
Address

Street Address

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Postal / Zip CodeCountry
Cell Phone
Format: (000) 000-0000.
Patient E-Mail
How did you hear about Enhance Peptides & Longevity?
Program Information
Medical Allergies
If yes
Primary Wellness Goals* (check all that apply)

Other
Have you used any peptides in the past? If so, please select which
Present Health
Please describe your present health concerns and their duration.
How long have you had the chronic conditions about which you are consulting us?
How have your health problems progressed since they began?
Please indicate the overall intensity of your symptoms.
Do you take any nonprescription drugs, vitamins and/or any other supplements? Please list them.
Do you currently take medication and/or receive medical treatment for your health condition(s)? If so, include all medications, treatments, and dosages.
Do you have any past medical history or problems (i.e.. illness, trauma, emotional stress, addictions, drug abuse, or anything else that will help us clearly understand your health condition)?
Miscellaneous
Do you have any allergies? If yes, please list them.
Have you had any surgeries? If so, please specify.
How would you rate your usual energy level?
Do you experience any of the following?
Consent for Peptide Therapy

I voluntarily consent to peptide therapy, understanding its goals include improved vitality, recovery, and body composition. I understand risks may include fatigue, water retention, headaches, or hormonal changes. I agree to periodic monitoring including bloodwork. I understand results are not guaranteed.
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Patient Information

Program Information

Present Health

Miscellaneous