Peptide Therapy Screening Form
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What peptide treatments are you interested in? (Check all that apply)
Semaglutide (weight loss)Glutathione
Tirzepatide (weight loss)
NAD+: Energy, Focus + Healthy Aging
Glutathione Skin Brightening + Antioxidant Support
BPC-157: Injury Healing + Inflammation Support
MOTS-C: Metabolic Optimization
GHK-Cu: Skin + Collagen Regeneration
Epithalon: Longevity + Sleep Support
PT-141: Sexual Wellness Desire/Arousal) Support
TB-500: Performance + Muscle Recovery
KPV: Inflammation + Gut Support
Are you interested in any of the following peptide stacks? (Check all that apply)
BPC-157/GHK-Cu/KPV/TB-500
BPC-157/TB-500/GHK-Cu
BPC-157/KPV/TB500
NAD +KPV + GHK-Cu
NAD + GHK-Cu
MOTS-C: Metabolic Optimization
GHK-Cu: Skin + Collagen Regeneration
Glutathione + GHK-Cu
GHK-Cu/Epithalon
Other
Screening Questions
Please check Yes or No for each
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you have liver, kidney, or heart disease?
*
Yes
No
Do you have a history of cancer?
*
Yes
No
Do you have a history of asthma?
*
Yes
No
Are you currently taking any prescription medications?
*
Yes
No
Are you taking any supplements or herbs?
*
Yes
No
Have there been any major changes in your health since your last visit?
*
Yes
No
List out all current medication
List out allergies
Intake & Processing Fee
A $35 non-refundable processing fee is required to begin your intake. This fee covers a comprehensive review of your information by a Registered Nurse, who will then collaborate with our Medical Director to determine your eligibility for treatment. Once your intake has been submitted, a member of our licensed staff will reach out to collect the $35 processing fee and guide you through the next steps
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
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