Peptide Consultation Form

Personal Information

Name*

First

Last

Date of Birth*

Gender*

Contact Number*

Email Address*

Street Address*

Apt / Suite

City*

State*

Zip*

Medical History

Current Health Concerns/Goals for Peptide Use*

Previous or Existing Medical Conditions*

Medications (prescription, over-the-counter, supplements)*

Allergies (food, medication, environmental)*

Previous Surgeries or Hospitalizations*

Family History of Medical Conditions*

Peptide Information

Have you used peptides before?*

Yes

No

If yes, please provide details on the type of peptide(s) used and the duration*

Are you familiar with the specific peptide(s) you are interested in using?*

Yes

No

If yes, please provide the names of the peptide(s) and any specific questions you have*

What benefits are you seeking from peptide use?*

Do you have any preferences or concerns about the method of administration (injection, oral, etc.)?*

Are you currently pregnant or breastfeeding?*

Yes

No

N/A

Are you currently under the care of a physician or specialist?*

Yes

No

If yes, please provide their name and contact information*

Have you had any recent significant life events or stressors?*

Yes

No

If yes, please provide details*

Additional Comments

Liability Waiver and Consent:
I, the undersigned, hereby acknowledge that I am aware that the use of peptides involves potential risks and side effects. I understand that the information provided in this consultation form is for evaluation purposes only and does not constitute medical advice or treatment recommendations. I voluntarily choose to use peptides, and I assume full responsibility for any adverse effects that may result from their use. I hereby release and discharge the healthcare provider and their affiliates, employees, and representatives from any liability, claims, demands, or actions arising out of or related to the use of peptides.

By checking this box I indicate that I have read, understood, and agreed to the terms outlined above.*

I agree

Type Name*

Date*

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