Full Name *

Date of birth *

Height / Weight

Phone *

Email *

Sex

Address

Street Address

Preferred Pharmacy Shipping State

Primary Care Provider

Date of Last Physical Exam

Emergency Contact

By checking this box, I consent to receive non-marketing text messages from The Primary Care and Wellness Clinic of Arlington about healthcare appointment reminders and wellness program updates. 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 The Primary Care and Wellness Clinic of Arlington at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Please rate each area of your health from 1 (poor) to 10 (excellent)

Energy Level

Sleep Quality

Stress Level

Recovery After Exercise

Mental Clarity

Mood

Digestion

Libido

Motivation

Exercise Performance

Please provide information about your current medications and supplements.

Current Medications

Current Supplements

Allergies

Currently Using Peptides

Yes

Previous Peptide Use

Yes

Previous GLP-1 Use

Yes

Testosterone / HRT History

Yes

Tell us about your daily habits and lifestyle

Exercise Frequency

Alcohol Use

Tobacco / Nicotine Use

Yes

Sleep Habits

Activity Level

Daily Protein Intake

Please read and acknowledge the following before submitting your intake form

Compounded peptide therapies are prescribed based on individualized provider evaluation and are not FDA-approved for all indications. Treatment plans are customized based on your medical history, goals, and provider assessment. Results may vary.

Off-Label Acknowledgment *

I understand that some therapies discussed may be off-label or investigational and that outcomes may vary significantly between individuals

Provider-Guided Treatment Agreement *

I agree to participate in provider-guided treatment and understand that no guarantee of specific results has been made

Telehealth Consent *

I understand that portions of my care may occur through telemedicine or electronic communication platforms

Financial Responsibility *

I understand that most wellness services are cash-pay and may not be covered by insurance. Payment may be required before services or prescriptions are provided

Please upload the following documents to complete your intake. Government-issued ID is required.

Government-Issued ID *

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