Peptide Therapy Intake

1- Patient Information

Full Name *

Date of birth *

Gender *

Height

Weight

Email *

Phone *

Address

Street Address

City

State

Country

Postal Code

Emergency Contact (Name & Phone)

2- Reason for Consultation

3- Medical History

4- Surgical History

List all past surgeries & approximate dates:

5- Current Medications

(List all prescription, OTC, vitamins, and supplements)

6- Allergies

Do you have any allergy?

No known allergies

Drug allergies: ___________________________________

Food allergies: ___________________________________

Environmental allergies: ____________________________

7- Lifestyle

Weekly Exercising:

None

1-2x

3-4x

5+ Times

Alcohol:

None

Occasionally

Weekly

Daily

Tobacco / Nicotine:

Never

Former

Current

Recreational drugs:

Yes - (List): ______________________

No

8- Current Symptoms or Concerns

E. Sleep

Trouble falling asleep

Waking up frequently

Not feeling rested

F. Skin / Hair

Wrinkles / aging

Skin dryness

Hair thinning

Loss of elasticity

G. Pain / Inflammation

Joint pain

Muscle pain

Chronic inflammation

H. Immune Function

Frequent illness

Poor recovery

Autoimmune flares

I. GI Health

Bloating

Slow digestion

Poor nutrient absorption

9. Peptide Goals

What are your top 3 goals for peptide therapy?

10. Safety Screening

Continue to Consultation?

Would you like to continue with the Peptide Consultation? *

Yes

No

CLICK HERE TO READ: INFORMED CONSENT FOR PEPTIDE THERAPY

Patient Full Name

D.O.B.

Date:

Clinic: MD Touch Aesthetics and Wellness

Patient Name
Patient Signature
Date
Provider Name
Date

YES. By checking this box, I consent & Want to submit and Schedule an appointment with the Physician.

“I have read and understand the information above. I agree to the terms of peptide therapy and wish to submit this consent form.

NO. By checking this box, I decline and do not wish to continue.

To schedule your consultation with our physician (virtual or in-person), please complete the payment below.
Once your payment is received, a member of our team will contact you promptly to finalize your appointment details.

Continue to Payment *

$ 75

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