First Name

Last Name

Date of birth

Phone *

Email *

Address

Street Address

City

State

Country

Postal Code

What are your top wellness priorities? *

What are your health goals that you hope peptide therapy can help with? *

Current Weight (lbs)

Complete if weight loss is your goal.

Goal Weight (lbs)

Complete if weight loss is your goal.

Do you currently take any of the following medications? *

Please list any medications or supplements you take regularly *

If none, please type none

If you checked cancer, blood clots, or liver issues, please share anything you're comfortable with.

Have you used peptides before *

Select One

If yes, which peptides have you used and how did you do on them?

Are you currently on a GLP-1 medication?

If yes, which one and what dose (if known)?

How would you rate your sleep?

How many days per week do you exercise?

How much water do you drink daily?

Estimate in ounces

How would you rate your stress?

Which peptides are you interested in?

When would you like to get started?

Are you comfortable with nighttime injections (often recommended for GH peptides)? *

Yes

Are you able to avoid eating 2 to 3 hours before injection for best results? *

Yes

List any current supplements

I understand that wellness peptides are not a prescription medication, and individual results vary. *

Yes

I understand this form is for wellness guidance only and is not medical advice; I agree not to stop or change prescription medications without talking to my doctor *

Yes, I agree

By checking this box, I consent to receive non-marketing text messages from Fountain of Youth Wellness about Peptide Therapy. Message frequency varies; message & data rates may apply. Text HELP for assistance; reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Fountain of Youth Wellness at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance; reply STOP to opt out.