Have you been referred by anyone?
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Yes
No
If YES: Type Name of Referral below If NO: Type "N/A" below
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What peptides are you interested in?
Semaglutide
Tirzepatide
Retatrutide
5 - Amino - 1MQ
GHK - Cu Cream
PT - 141
LGD - 4033
Sermorelin
Tesofensine
Thymulin
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If you don't see what you are looking for, please describe below:
Are you currently taking GLP- Medications? If YES, what dosage and when was your last injection? What have been your results?
First Name
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Last Name
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Date of birth
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Phone
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Address
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City
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State
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Postal code
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Email
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Who is your Primary Care Provider
Please list any allergies
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What is your current weight in pounds?
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What is your goal weight in pounds?
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What is your height in feet?
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What is your height in inches?
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Please check all that apply
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Pregnant, breastfeeding or trying to get pregnant
Personal or family history of thyroid cancer
Multiple endocrine neoplasia syndrome type 2
History of pancreatitis
Taking other Diabetes Melllitus medications
Tachycardia
Taking other weight loss medications, including over the counter
History of gall bladder disease
Retinopathy
Active military or entering the military
CURRENT High school, college or professional athlete
NONE of the above
If you marked any of the above, please explain below:
Please list your prescribed medications and over-the-counter medications, such as vitamins and supplements:
Mental Health: Please check all that apply
Stress is a major problem for me
I feel depressed
I panic when stressed
I have problems with eating and/or my appetite.
I cry frequently
I have attempted suicide (past or present)
I have seriously thought about hurting myself (past or present)
I have trouble sleeping
I have seen a counselor (past or present)
NONE of the above
I understand that any medical concerns not directly related to peptide therapy needs to be discussed with my Primary Care Provider. Radiant Revival Aesthetics & Weight Loss clinic assumes zero responsibility for medical services, treatment or discussion outside peptide therapy. Please initial:
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I acknowledge I need to notify Radiant Revival Aesthetics & Weight Loss Clinic of any upcoming procedures that require sedation or anesthesia. I understand I will need to stop my weight loss injections 7 days prior to my procedure. Please initial:
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RETURN/EXCHANGE POLICY:ALL SALES ARE FINAL AND NO REFUNDS, RETURNS, OR EXCHANGES WILL BE ACCEPTED. Please initial
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I hereby authorize Radiant Revival Aesthetics & Weight Loss Clinic and its Medical professionals to prescribe Peptide Therapy. I recognize that during the course of the procedure unforeseen conditions may necessitate different procedures than those above. I therefore authorize Radiant Revival Aesthetics & Weight Loss Clinic or its designees to perform such other procedures that are in the exercise of his or her professional judgement necessary and desirable. The authority granted under this paragraph shall include all conditions that require treatment and are not known to my provider at the time of procedure is begun. I understand that Radiant Revival Aesthetics & Weight Loss Clinic practitioners will monitor my treatment in an effort to prevent any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy. I understand the use of this treatment does not preclude me from using other treatments as well, though I recognize that I should inform any practitioners I am seeing about the various treatments I am using. I understand and have been advised that I should not receive peptide therapy if I have the following conditions: misusing or dependency on any drug, pregnant, lactating, or planning to become pregnant within the next 8 months, history of thyroid cancer, pancreatitis, endocrine, psychiatric, or neurological diseases including seizures, hepatic or renal dysfunction, untreated thyroid disease, malabsorptive intestinal disorder, surgically treated obesity, systemic infection or inflammatory disease, significant electrocardiogram, consistent heart rate of more than 90 beats per minute, HIV infection or serological evidence of hepatitis B or C, cancer within the past 5 years (excluding treated basal cell carcimona), clinically significant eye disorder, or treatment with a drug known ocular toxic effects. Off-label FDA issues: There are many devices, medications, and injectable fillers and botulinum toxins that are approved for specific use by the FDA, but this is proposed use is "Off-Label", that is not specifically approved by the FDA. It is important that you understand this proposed use not experimental and your injector believe it to be safe and effective. Examples of commonly accepted "Off-Label" use of drugs or devices include the use of aspirin for prevention or heart disease, retinoids for skin care, and injection of botulinum toxin for wrinkles around the eyes. I acknowledge that I have been informed about the Off-Label FDA status of Peptides. IT HAS BEEN EXPLAINED TO ME IN A WAY THAT I UNDERSTAND: -THE ABOVE TREATMENT OR PROCEDURE TO BE UNDERTAKEN -THERE MAY BE ALTERNATIVE PROCEDURES OR METHODS OF TREATMENT -THERE ARE RISKS TO THE PROCEDURE OR TREATMENT PROPOSED -NOT RECEIVING PEPTIDE THERAPY IS AN OPTION I understand there are no guarantees as to the result of the treatments, due to many variables including but not limited to: age, condition of skin, sun damage, smoking, climate, etc. Although complications are very rare, sometimes they may occur. If I have complications or concerns I need to immediately contact Radiant Revival Aesthetics & Weight Loss Clinic. I hereby agree to the above and agree to have this treatment be performed on me. I further agree to follow post-procedure instructions as directed by my provider. I cannot hold Radiant Revival Aesthetics & Weight Loss Clinic or my provider responsible if I do not follow protocol. By signing below, I understand what is expected of me.
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