Peptide Ordering Form

Healing Peptides Intake Questionnaire

(Complete this form to request peptide therapy. Your responses will be reviewed by a licensed

provider. Some cases may require a telehealth visit before approval.)

First Name

Last Name

Date of Birth (MM/DD/YY)

Phone *

Email *

State of Residence

What is your gender? *

Male

Female

Other

Medical History

Do you have any current medical diagnoses? (check all that apply) *

Diabetes

High blood pressure

Heart disease or arrhythmia

Kidney disease

Autoimmune condition

Cancer (current or past)

None of the above

Please list any other chronic medical conditions:

Have you had surgery in the past year? *

Yes

If yes, please describe:

Medications & Allergies

Are you currently taking prescription medications?

Yes

If yes, please list:

Do you take blood thinners (e.g., warfarin, Eliquis, Plavix)?

Yes

Do you have any medication allergies?

Yes

If yes, list medication(s) and reaction:

Peptide Use & Goals

Which peptide(s) are you interested in? (check all that apply) *

BPC-157 (tissue/joint healing, gut support)

Thymosin Alpha-1 (immune support)

Thymosin Beta-4 (healing/recovery)

GHK-Cu (skin, hair, tissue repair)

What are your main goals with peptide therapy? *

Injury recovery

Post-surgical healing

Gut health support

Immune system support

Skin/hair/tissue repair

Other

Have you used peptides before? *

Yes

If yes, which ones?

Health & Safety Screening

Are you currently pregnant, trying to become pregnant, or breastfeeding? *

Yes

Do you have a history of active or recent cancer? *

Yes

Do you have any uncontrolled medical condition (such as uncontrolled diabetes, uncontrolled hypertension, or active infection)? *

Yes

Are you currently under the care of another specialist for your condition? *

Yes

Consent & Acknowledgment

By signing below, I confirm that the information provided is accurate and complete. I understand that:

● A licensed provider will review this form to determine if peptide therapy is appropriate.

● Additional labs or a telehealth visit may be required before approval.

● Peptides are for personal use only and must be used as prescribed.

Peptide Order Signature *

Clear

Peptide Order Date