• Telehealth Intake Form – Medical Assessment Required

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  • Start by filling out this form to see if you’re eligible for Eternelle’s Rx treatment products.

  • By clicking "Continue" button, I agree to the Terms and Conditions and Telehealth Consent and acknowledge the Privacy Policy

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  • Sorry, your area is out of our service!

  • How Did You Hear About Us?*

  • Eligibility check

  • Personalized care starts here

     
    To access our Rx products, your answers must be reviewed by a licensed doctor. Please provide accurate information.
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  • Getting To Know You

  • Just a few quick details so we can stay in touch.

  • Format: (000) 000-0000.
  • What is your birth date?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • What would you like help with today?*

  • 🔥 Weight Loss

    Answer a few questions to help our provider understand your goals and determine the most appropriate weight management approach.
  • Have you recently discontinued the use of a weight loss medication?*
  • Are you currently on any other weight loss medication and switching to us?*
  • Check the conditions that apply to you or any member of your immediate relatives:*
  • Check the symptoms that you' re currently experiencing:*
  • Do you have any of the following conditions? (check all that apply)*
  • Have you ever had pancreatitis?*
  • Do you have any of the following allergies:*
  • How much weight are you looking to lose*
  • Do you use any kind of tobacco or have you ever used them?*
  • Do you use any kind of illegal drugs or have you ever used them?*
  • Have you had any major surgery in the past 6–12 months?*
  • Are you taking any diabetes medications? (e.g., insulin, metformin, etc.)*
  • Are you currently using any GLP-1 medications?*
  • Is there a specific weight management treatment or approach you’d like to discuss with your provider?*

  • ✨ Skincare Treatments

    Tell us about your skin concerns so our provider can better understand your needs.
  • What are your main skin concerns?*
  • How long have you had this condition?*
  • How would you describe your skin type?*
  • How sensitive is your skin? (1 = not sensitive, 5 = very sensitive)*
  • What is your Fitzpatrick skin type?*
  • How does your skin typically react to sun exposure?*
  • How often are you exposed to direct sunlight?*
  • Do you develop dark marks easily after acne or irritation?*
  • Do you experience any of the following?*
  • Are you willing to apply sunscreen daily (and reapply if needed)?*
  • Are you currently using any prescription skin or hair treatments?*
  • Have you used any of the following before?*
  • Do you have any diagnosed medical conditions?*
  • Have you ever had a severe reaction to skincare or treatments?*
  • Do you currently have any of the following on the treatment area?*
  • Have you experienced any of the following recently?*
  • Are you willing to follow a consistent skincare or treatment routine for at least 3–6 months?*
  • Have you used retinoids before?*
  • Do you have hormonal or endocrine conditions?*
  • Where do you plan to apply the product?*
  • Have you ever been diagnosed with an estrogen-sensitive condition?*
  • What are you trying to treat?*
  • Choices:*
  • Have you used prescription acne or pigmentation treatments before?*
  • Do you have sensitive skin?*
  • Do you experience hormonal acne (jawline/chin)?*
  • Have you been diagnosed with hormonal imbalance?*
  • Do you have kidney or blood pressure issues?*
  • What type of acne do you have?*
  • How does your skin react to strong treatments?*
  • Do you have inflammatory or cystic acne?*
  • Have you used dapsone or similar treatments before?*
  • Do you have any blood or kidney conditions?*
  • Do you have any of the following?*
  • What are your main goals?*
  • Are you comfortable using hormone-based skincare (estriol)?*
  • What concerns are you targeting?*
  • Are you comfortable using hormone-based products?*
  • Have you used vitamin C before?*
  • Are you comfortable using finasteride-based products?*
  • Are you currently under physician care for a condition?*
  • Have you used steroid or hydroquinone creams before?*
  • Are you willing to use strict sun protection daily?*
  • Have you experienced skin thinning or irritation?*
  • Have you used combination bleaching treatments before?*
  • Have you been diagnosed with rosacea?*
  • What symptoms you experienced:*
  • Do you experience persistent facial redness?*
  • Are you under medical supervision for Naltrexone HCI*
  • Are you comfortable using nighttime retinoid treatments?*
  • Have you used exfoliating or resurfacing treatments before?*
  • Do you have sensitive skin around the eyes?*
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  • Is there a specific skin treatment or approach you’d like to discuss with your provider?*

  • 🧴 Hair Treatments

    Share details about your hair concerns to help us identify the best approach for you.
  • Do you have any upcoming lab work scheduled in the next 2 weeks?*
  • What is your main hair concern? (check all that apply)*
  • Are you currently using any treatments for hair loss?*
  • When did hair concerns start?*
  • Since it started, your hair loss has been:*
  • Is your hair loss:*
  • Have you ever been diagnosed with a hair loss condition by a healthcare provider?*
  • Do you have any scalp symptoms?*
  • Does hair loss run in your family?*
  • Have you used peptide-based or advanced hair therapies before?*
  • Are you comfortable using peptide-based treatments?*
  • Any recent triggers in the past 6 months? (check all that apply)*
  • Check if you have EVER been diagnosed with:*
  • For GI / Bleeding Screening, check if you currently have:*
  • For Symptoms Screening, check if you currently have:*
  • For women: heavy periods?*
  • Have you ever been diagnosed with any hormonal conditions?*
  • Are you soaking through pad/tampon within 1–2 hours?*
  • Passing large clots?*
  • Are you currently under the care of a doctor or dermatologist for hair loss?*
  • Are you currently taking any of the following? (check all that apply)*
  • Are you currently taking:*
  • What is your diet type?*
  • Any known nutritional deficiencies?*
  • Have you had any blood tests related to hair loss in the past 6 months?*

  • 🏃‍♀️‍➡️ Healing & Performance

    Help us understand your recovery and performance goals so our provider can better evaluate your needs.
  • What are your main healing or performance concerns?*
  • Are you currently dealing with an injury?*
  • What type of injury?*
  • How long has the injury been present?*
  • Have you had imaging (MRI, X-ray, etc.)?*
  • Do you currently have an injury or chronic pain?*
  • Duration of condition*
  • Have you tried other treatments?*
  • Do you experience any of the following?*
  • Have you had hormone testing done?*
  • Which tests have you had?*
  • When was your most recent test?*
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  • Have you used hormone therapy or peptides before?*
  • How would you describe your sleep?*
  • Do you have trouble:*
  • Do you feel fatigued during the day?*
  • Have you been diagnosed with any of the following?*
  • Are you currently trying to lose weight?*
  • Have you ever had cancer?*
  • Do you have any unexplained lumps or growths?*
  • Are you willing to undergo lab testing if required?*
  • Have you ever been told by a healthcare provider that you have diabetes or problems with blood sugar?*
  • Have you ever been diagnosed with any hormonal or endocrine condition?*
  • Have you ever been diagnosed with any of the following heart or blood vessel conditions?*
  • Is there a specific healing & performance treatment or approach you’d like to discuss with your provider?*

  • 🧬 Longevity & Vitality

    Tell us about your energy, wellness, and lifestyle so we can better evaluate your goals.
  • What are your main wellness or vitality concerns?*
  • How long have you been experiencing this concern?*
  • Have you tried other treatments?*
  • How would you rate your current energy levels?*
  • How long have you experienced low energy or fatigue (if applicable)?*
  • Do you currently experience any of the following?*
  • Have you been diagnosed with any of the following?*
  • Have you used NAD⁺ or related therapies before?*
  • What type?*
  • Are you currently taking any antidepressant or psychiatric medications?*
  • Have you ever been diagnosed with G6PD deficiency?
  • Do you have any of the following conditions?*
  • Are you currently experiencing unexplained fatigue that has NOT been medically evaluated?*
  • Are you currently taking any of the following?*
  • Have you used glutathione before?*
  • What form have you used?*
  • What sleep issues are you experiencing?*
  • How many hours do you sleep per night on average?*
  • Have you used sleep aids before?*
  • Do you use screens before bed?*
  • Do you snore or have breathing interruptions during sleep?*
  • Do you experience daytime sleepiness?*
  • Do you work shifts or have an irregular schedule?*
  • Have you noticed persistent brain fog or difficulty concentrating that has not been medically evaluated?*
  • Have you ever been diagnosed with any of the following metabolic conditions?*
  • Do you have difficulty maintaining a healthy weight despite diet and exercise?*
  • Have you ever been diagnosed with ANY of the following? (Select all that apply)*
  • Have you had your blood pressure checked in the last 6 months?*
  • Any recent medication changes?*
  • Have you ever been diagnosed with impaired liver or kidney function?*
  • Do you currently have a primary care provider?*
  • Do you smoke?*
  • What is your alcohol consumption?*
  • Do you currently use recreational drugs?*
  • Is there a specific longevity & vitality treatment or approach you’d like to discuss with your provider?*

  • 💊 Hormone & Sexual Health

    Share details about your symptoms to support a thorough evaluation.
  • What are your primary goals for improving your hormone and sexual health?*
  • How long have you been experiencing this concern?*
  • Do you have any diagnosed medical conditions?*
  • Have you been diagnosed with a reproductive or endocrine disorder?*
  • Any surgeries or hospitalizations in the past 12 months?*
  • Are you currently on hormone-related treatments?*
  • Are you taking supplements or peptides?*
  • What symptoms are you currently experiencing?*
  • Have you ever had any of the following?*
  • Do you have uncontrolled high blood pressure or low blood pressure?*
  • Have you had a heart attack, stroke, or other serious cardiovascular event within the past 6 months?*
  • Are you currently taking any nitrate medications for chest pain or heart disease (e.g., nitroglycerin, isosorbide)?*
  • Is there a specific hormone & sexual health treatment or approach you’d like to discuss with your provider?*
  • Are you currently taking any medication?*
  • Do you have any known allergies or sensitivities (medications, peptides, etc.)?*
  • Are you currently pregnant or trying to become pregnant?*
  • Are you breastfeeding?*
  • TERMS & CONDITIONS*

  • Face Photo

  • Upload your face photo

  • To proceed with treatment, we need a clear photo of your face.

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  • Make sure your photo

    • Clear and well-lit
    • Only you in the frame
    • No filters or edits
    • Taken within 30 days
    • Full face visible

  • By clicking “Continue,” you allow us to use your photos for identity verification and secure third-party processing. We do not store biometric information. For more information, please see our Privacy Policy.

  • Signature Consent

  • Please note that it could take 2-3 working days in order for the doctor to review your information. Thank you!

  • Bloodwork

    Bloodwork is required for our physician to review. This is to protect YOU! If you have bloodwork within the last 90 days you can upload the results below. If you do not have bloodwork, we can set you up at a Quest Diagnostics near you.
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