AV Wellness Intake

Peptide History
Have you previously used a GLP-1 medication? *
Semaglutide (GLP-1, Wegovy or Ozempic)Tirzepatide (GLP-1 and GIP, Mounjaro, Zepbound)Other
Highest dose taken?
Date last used?
Side effects (if any):
Goals:
(Weight loss / Metabolic health / Other)
Goal Weight:

CONSENT
I agree
Signature*

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Thank you for completing your intake. Our team will carefully review your information, and you will be contacted within 24 business hours regarding approval and next steps.

If you wish to move forward, you may complete the one-time activation fee now to expediate activation process. One-time activation fee will be due upon approval and prior to ordering any products. Should you not be medically qualified, the activation fee will be fully refunded.

For any additional questions or support, our team is available at (801) 880-8108 or info@av-wellness.com.
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Intake