Peptide Therapy Intake Form

Peptide Therapy Screening Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender

FemaleMale
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What peptide treatments are you interested in? (Check all that apply)

Semaglutide (weight loss)GlutathioneTirzepatide (weight loss)NAD+: Energy, Focus + Healthy AgingGlutathione Skin Brightening + Antioxidant SupportBPC-157: Injury Healing + Inflammation SupportMOTS-C: Metabolic OptimizationGHK-Cu: Skin + Collagen RegenerationEpithalon: Longevity + Sleep SupportPT-141: Sexual Wellness Desire/Arousal) SupportTB-500: Performance + Muscle RecoveryKPV: Inflammation + Gut Support
Are you interested in any of the following peptide stacks? (Check all that apply)

BPC-157/GHK-Cu/KPV/TB-500BPC-157/TB-500/GHK-CuBPC-157/KPV/TB500NAD +KPV + GHK-CuNAD + GHK-CuMOTS-C: Metabolic OptimizationGHK-Cu: Skin + Collagen RegenerationGlutathione + GHK-CuGHK-Cu/EpithalonOther
Screening Questions

Please check Yes or No for each
Are you currently pregnant or breastfeeding?*

YesNo
Do you have liver, kidney, or heart disease?*

YesNo
Do you have a history of cancer?*

YesNo
Do you have a history of asthma?*

YesNo
Are you currently taking any prescription medications?*

YesNo
Are you taking any supplements or herbs?*

YesNo
Have there been any major changes in your health since your last visit?*

YesNo
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*

MonthDayYear
Date
Should be Empty:

Peptide Therapy Screening Form

Screening Questions

Intake & Processing Fee