Clinical Intake

Peptide Therapy Screening

Step 1 of 3 — Eligibility Screening

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Before We Get Started

We take your safety seriously. Please answer honestly — your responses are reviewed by our clinical team.

Your Contact Information

Shipping Address

Are you currently pregnant or breastfeeding? *

Have you ever been diagnosed with active cancer or are you currently undergoing cancer treatment? *

Height & Weight (for BMI reference)

Do you have any of the following conditions? (check all that apply)

Are you currently taking any of the following medications? (check all that apply)

Do you currently use tobacco, alcohol heavily (more than 14 drinks/week), or recreational drugs?

Have you or any first-degree family members been diagnosed with Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia type 2 (MEN2)?

Are you currently under the care of a physician for any serious or chronic medical condition?

Are you currently experiencing or have you recently experienced thoughts of self-harm or suicide? *

⚠️ If you are experiencing a medical emergency, call 911 immediately. Do not use this form.

Your information is protected and used only for clinical review purposes.