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Peptides
About Us
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Client Intake Form
First Name
Last Name
Address
Street Address
Street Line 2
City
State
--Select State--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
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Hawaii
Idaho
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Indiana
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
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New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Weight
Height
Gender
Male
Female
Email
Date of Birth
Phone Number
Drivers License #:
As a telemedicine provider company, your picture ID (driver's license, State ID, or passport) is a prerequisite for any of our services to verify your age and identity
Which Treatment are you interested in?
IV Infusion
TRT
Peptides
Have you ever had an infusion before?
Yes
No
Have you ever done Hormone replacement therapy before?
Yes
No
Have you got blood work done in the past 30 days?
Yes
No
General Health
Excellent
Good
Fair
Poor
Medical History - Identify any present and past health concerns.
Hypertension
Past
Present
Abnormal Heart Rhythms
Past
Present
Bleeding/Clotting Disorder
Past
Present
Sudden Weight Loss
Past
Present
Chest Pain
Past
Present
Chronic Heart Failure
Past
Present
CVA/Stroke/TIA or mini-stroke
Past
Present
Thyroid Problems
Past
Present
Kidney Disease
Past
Present
Depression
Past
Present
Anxiety/Panic Attacks
Past
Present
Asthma
Past
Present
Diabetes
Past
Present
Ankle Swelling
Past
Present
Generalized Edema
Past
Present
Are you pregnant?
Past
Present
Allergic Reactions
Past
Present
Seizures
Past
Present
Anemia
Past
Present
Head Injury
Past
Present
Comments on your Medical History
Details of any of the above or any other medical considerations, i.e.: Autoimmunity, chronic illnesses, mold toxicity, viral illness, parasites, bacteria/yeast infection, neurological conditions, alcoholism, cancer, frequent infections, arthritis, nutritional deficiencies, etc.
Describe any current symptoms and duration if not addressed above, i.e.: GI upset, skin problems, pain, inflammation, headaches, sleep problems, fatigue,
Treatments or therapies tried:
Have you had a COVID-19 vaccination and Booster? If yes, please indicate when you received your last dose. If you plan on getting the vaccine soon, please indicate your scheduled date as this is important when considering IV therapy. Also note if you have received a Booster and date.
Current Medications: (Include prescriptions, over-the-counter medicines, supplements/vitamins, etc. with dose/frequency)*
Allergies to any medications or foods: (List medication or food and reaction)*
Do you follow a special diet? if so, please describe.
Do you exercise? if so, what type of exercise?
How did you hear about us?
Signature
Type your Legal Full Name to Sign
Date of Sign
Consent
I have read the
Consent Terms & Conditions
and Agree.
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