AMS Intake

Thank you for your interest in Active Medical Solutions (AMS). We’re excited to support your health journey!

Returning patients: Please update as needed and complete required fields only.

Note: We currently serve new patients located in Alabama by approval only.

First name *

Last Name *

Sex at Birth *

Male

Female

Date of birth *

Phone number *

Please use a unique number not already registered in our system (if you are a new patient)

Email *

Please use a unique email not already registered in our system (if you are a new patient)

Street Address *

City *

State *

Country *

Postal code *

What medication are you requesting? *

Were you a patient with us before? *

I'm a new patient!

I'm coming back

Are you in any cancer treatment within the last 12 months? *

Yes, currently undergoing cancer treatment

Medication Allergies: *

Current Medications: *

Medical Conditions: *

Past Surgeries: *

Tobacco Use *

Alcohol Use *

Drug Use *

Height: *

Weight: *

Pharmacy Info: *

Include full address of pharmacy including zip

GLP-1, Peptides & Compounded Meds

You confirm you do not have a history of pancreatitis, gallbladder disease, medullary thyroid cancer, multiple endocrine neoplasia or suicidal thoughts.

You are not pregnant, plan to become pregnant, or nursing and will use backup contraception (IUD, implantable or barrier) if needed.

You acknowledge that:

Compounded medications may not be not FDA-approved.
There are potential risks and side effects, both known and unknown.
Pharmacies ensure the safety, sterility, and strength of medications.

You agree to contact your AMS team for concerns, seek emergency care if needed, and release AMS/providers from liability related to peptide use.

Testosterone Replacement Therapy

(For TEXAS & FLORIDA residents only)

You are seeking evaluation or treatment for symptoms of low testosterone. TRT aims to improve well-being by restoring hormone levels using injections, gels, or supportive therapies.

You understand:

Risks include cardiovascular issues, fertility impact, prostate changes, acne, mood shifts, sleep apnea, and other side effects.
TRT may be long-term and does not treat underlying causes.
Alternatives have been reviewed, including lifestyle changes and fertility-preserving options.

You agree to:

Regular labs and follow-ups every 3–6 months.
Use AMS for refills and avoid misuse (testosterone is a controlled substance).
Call 911 for emergencies and notify AMS of side effects.

TRT is elective, results are not guaranteed, and your active participation in care is essential.

I acknowledge that I have read and understood the terms of the testosterone replacement therapy (TRT) agreement and consent to proceed with the treatment as outlined.

Not Applicable (I am outside of Texas or Florida or will not seek testosterone replacement)

Acknowledgements

You are voluntarily enlisting our services and may cancel at any time after your prescription is completed.
Medical care fees are separate from medication or lab fees and must be rendered at the time of service.
You consent to receiving care and billing-related text messages.
We require a copy of your Government Issued ID and a current photo before prescribing.
Video/audio calls require scheduling. Group calls are not HIPAA-compliant.
AMS is unaffiliated with any pharmacy and cannot control their fees or processing times.
Prescriptions may not be refundable once sent. Changes may incur fees.
Dosing may vary with compounded medications. Follow your provider’s prescription.
Contact your success team for refills. Refills are not automatic.
Maintain a local primary care physician for in-person care.
AMS does not accept insurance (including Medicare/Medicaid). You are financially responsible.

By continuing, I acknowledge that I have read and agree to the Terms of Service, Privacy Policy, Consumer Disclosures, and Refund Policy.

Electronic Records and Signature Consent to Treat *

I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure

Signature *

Date Signed: *

ID Verification

If you’re new here, please upload a government-issued ID and a selfie or recent photo to help us verify your identity for medical care.

Note: These fields are optional and can also be submitted later once you receive our welcome text.

Government-Issued ID

Selfie / Recent Photo