Regenix core health intake

Regenix Core Health is a physician-directed, cash-pay performance and optimization program. Enrollment is limited during our initial rollout phase to maintain safety, quality, and physician oversight. Completion of this form does not guarantee acceptance. Approved applicants will be contacted by our team.
Form

Regenix Core Health – Enrollment Inquiry
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Primary care provider *
N/A if no primary care currently
Weight loss / metabolic optimizationHormone optimization (TRT evaluation)Recovery and regeneration protocolEnergy & cognitive optimizationMuscle building / fat loss
Are you currently using any peptides, hormones, GLP-1 meds, or performance enhancing therapies? *
If yes, please list medication names, dosages, and how long you have been using them.
I understand this is a cash-pay program and is not billed to insurance.I understand this program is separate from primary care services.I understand this is a structured monthly program, not a one-time visit.I am prepared for a minimum 3-month commitment.
Why are you interested in Regenix Core Health at this time?*
On a scale of 1–5, how committed are you to lifestyle change alongside medical optimization?*

1

2

3

4

5

1 is Exploring/curious, 5 is Fully committed
Submissions are reviewed weekly. If approved for enrollment, a member of our team will contact you to discuss next steps.
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