Please select whether this is a new patient visit or a follow-up appointment.
Please select the treatment(s) you're receiving today.
Please answer the following questions for each selected treatment.
Please select all that apply:
Do you have diabetes?*
Do you have heart disease?*
Do you have high blood pressure?*
Do you take blood thinners?*
Are you currently on hormone therapy?*
Have you tried any treatments for sexual wellness concerns in the past? If so, please describe:
What are your goals for sexual wellness treatment?
Dehydration issues?*
Nutritional deficiencies?*
Please select all medical conditions that apply to you.
Please select all that apply: *
Please indicate if you have previously used a commercially available GLP-1 medication (e.g., Zepbound, Mounjaro, Ozempic):*
Check all that apply. These will guide your personalized formulation:
Please check all that apply
Have you previously undergone Stem Cell/Exosome therapy?*
What results or outcomes are you hoping to achieve with this treatment?*
Do you have any concerns or questions regarding Stem Cell/Exosome therapy?*
Please answer the following questions to determine your eligibility for peptide therapy.
History of or active cancer (within last 5 years)?*
Pregnant or currently breastfeeding?*
History of severe allergic reactions or anaphylaxis to medications?*
Currently have uncontrolled high blood pressure (>160/100 mmHg)?*
Currently undergoing chemotherapy or radiation treatment?*
Currently diagnosed with untreated autoimmune disease?*
Current active infection or illness?*
History of significant heart disease or recent cardiovascular event (within 6 months)?*
Current or recent (within 5 years) history of cancer/tumors not cleared by your oncologist?*
Please select all that apply*
I acknowledge that I have received and reviewed the Notice of Privacy Practices. I authorize the use and disclosure of my health information for the purposes of treatment, payment, and healthcare operations as outlined. I understand that I may revoke this authorization in writing at any time.
I voluntarily consent to receive medical care, evaluation, and treatment from this healthcare provider and their team. I understand that my treatment may include physical exams, diagnostic testing, or procedures deemed necessary by the provider.
I understand that Telehealth involves the use of audio, video, or other technology to receive care remotely. I acknowledge that I have the right to refuse or stop telehealth at any time and that confidentiality will be maintained as required by HIPAA. Risks include technical failure, unauthorized access, or limited access to emergency care.
I understand that Sexual Wellness treatments may include hormone therapy, sexual enhancement procedures, or counseling to address intimacy and sexual health concerns. I acknowledge that results vary and that potential risks may include hormonal imbalances, allergic reactions, discomfort during treatment, or unsatisfactory results. I agree to inform my provider of any pre-existing conditions or medications.
I understand that IV Infusion Therapy involves the administration of fluids, vitamins, minerals, and/or medications directly into the bloodstream. Potential risks include vein irritation, bruising, infection, or allergic reaction. I confirm I have disclosed my medical history and any allergies to the provider.
I understand that Peptide Therapy uses biologically active peptides to promote healing, weight management, or anti-aging effects. I acknowledge that this therapy may have risks including injection site reactions, dizziness, fatigue, or hormonal changes. I have disclosed all relevant health conditions to my provider.
I understand that Regenerative Medicine may include exosome therapy, PRP, or stem cell-based therapies aimed at repairing damaged tissues. These are often considered investigational and not FDA-approved. Risks may include infection, swelling, pain at injection site, or lack of improvement. I accept these risks and confirm I have provided my fullmedical history.
I understand that HRT involves the administration of hormones to address hormonal imbalances. Risks may include blood clots, breast tenderness, mood changes, or increased risk of certain cancers. I acknowledge that I have discussed these risks with my provider and have disclosed all relevant health history.
I understand that Weight Loss Therapy may include medications, dietary guidance, and/or injections. Risks may include nausea, dizziness, low blood sugar, or gastrointestinal discomfort. I acknowledge that outcomes may vary and that I am responsible for following the treatment plan provided.
I understand that GLP-1 medications are not a substitute for diet & exercise.
I agree to follow medical guidelines & dosage adjustments as needed.
I acknowledge the possible side effects (nausea, vomiting, GI issues, etc.).
I understand telehealth clearance does not guarantee approval.
I certify that the above information is accurate & complete.
I understand that Aesthetic Treatments may include cosmetic injections, facials, laser therapy, or other procedures to enhance appearance. Potential risks include bruising, swelling, allergic reaction, scarring, or dissatisfaction with the results. I confirm that I have no known contraindications and have shared my medical history.
By signing below, I confirm that all information provided is accurate and complete. I understand that this information will be used to determine my eligibility for treatment.
Please review your information before submitting.
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