PEPTIDE THERAPY INTAKE FORM

Complete before your consultation

Date of Birth (mm/dd/yyyy)*
Home Address (address, city, state, zip code)*
Primary Care Physician ( name and clinic)*
Marital status*
Allergies*
WHICH PROGRAM INTERESTS YOU?*
History of cancer or in cancer treatment*
Diabetes (Type 1 or 2)*
Currently pregnant or breastfeeding*
Thyroid problems*
Heart disease or high blood pressure*
Kidney or liver disease*
Current Tobacco Use (select all that apply)*
Alcohol Use*
CURRENT MEDICATIONS List all prescription medications you take:*
Family Health History (select all that apply)*
Medical History (select all that apply)*
YOUR TOP 3 SYMPTOMS (Check your worst 3)*
YOUR #1 GOAL*
Hours of sleep per night
Exercise frequency
How would you rate your diet?
COMMITMENT On a scale of 1-10, how committed are you to transforming your health
Following injection protocol consistently
Giving this 3-6 months to see full results
Making lifestyle changes if needed
Have you tried peptides before?
How did you hear about us?
WHAT ELSE SHOULD I KNOW?
Questions before your consultation? Text: 802 323 2632
See you soon! 💚 -Mia