Private & Personalized

Peptide Therapy Consultation

Complete the secure form below to help our team understand your wellness goals.

Start Your Peptide Therapy Intake

Complete all steps — takes about 8 minutes. Payment of $150 is collected after submission.

Step 1 of 11

Personal Information

Let's start with your basic details.

First Name *

Last Name *

Date of Birth *

Gender *

Height *

Weight *

Address *

Email *

Phone *

Reason for Consultation *

What brings you in? Select all that apply.

Low energy / fatigue Weight loss Muscle gain Anti-aging / longevity Hormonal imbalance Sleep issues Brain fog / focus Athletic performance Recovery / injury healing Immune support Sexual wellness General wellness N/A

Other (describe)

Your Goals

Describe what you hope to achieve with peptide therapy.

Primary goal *

How long have you been experiencing these concerns? *

Have you tried other treatments before? *

Medical History *

Select any conditions that apply to you.

Diabetes / prediabetes Thyroid disorder Heart disease High blood pressure High cholesterol Autoimmune disease Cancer history Kidney disease Liver disease Hormonal disorders (PCOS, etc.) Anxiety / depression Sleep apnea None of the above

Surgical history *

Other medical conditions not listed *

Current Symptoms *

How are you feeling right now? Select all that apply.

Fatigue Weight gain Hair loss Brain fog Poor sleep Mood changes Low libido Joint pain Muscle weakness Digestive issues Skin changes Frequent illness No current symptoms

Describe your symptoms in more detail *

Safety Screening *

Important questions to ensure your safety.

Are you currently pregnant or breastfeeding? *

No Yes Not applicable

Active cancer or treated in the last 5 years? *

No Yes

History of blood clots or clotting disorders? *

No Yes

Currently on hormone therapy or steroids? *

No Yes — will describe in medications step

Any other safety concerns? *

Allergies *

Please share any known allergies.

Allergy status *

No known allergies I have allergies

Drug allergies

Food allergies

Environmental allergies

Current Medications & Supplements *

List everything you're currently taking, including OTC and supplements.

Are you currently taking any medications? *

No medications Yes

Prescription medications

Over-the-counter medications

Supplements / vitamins

Lifestyle *

Help us understand your daily habits.

Exercise frequency *

Type of exercise

Diet / nutrition style *

Alcohol use *

Tobacco use *

Recreational drug use *

Additional Information

Anything else you'd like the physician to know?

Additional notes *

Informed Consent & Authorization

Please read and acknowledge the following before submitting.

1. Nature of Peptide Therapy

I understand that peptide therapy involves the use of amino acid sequences that signal biological processes. While evidence-based, some peptides are investigational and individual results vary.

2. Voluntary Participation

I voluntarily seek peptide therapy and understand I may discontinue at any time after consulting with the physician.

3. Risks & Benefits

I understand there are potential risks including injection site reactions, hormonal changes, and unknown long-term effects. Benefits may include improved energy, body composition, and recovery.

4. Physician Oversight

I understand all protocols are prescribed and supervised by a licensed physician. I will not self-administer without guidance.

5. Accurate Information

I certify all information provided in this form is accurate and complete to the best of my knowledge.

6. Privacy & Confidentiality

I understand my health information is protected under HIPAA and will only be shared as required for my care.

7. Laboratory & Follow-Up

I understand baseline labs may be required and agree to follow-up as recommended by the physician.

8. Off-Label Use

I understand some peptides may be used off-label and have been informed of this fact.

9. No Guarantee of Results

I understand MD Touch Aesthetics & Wellness makes no guarantee of specific outcomes from peptide therapy.

10. Payment Authorization

I authorize a $150.00 consultation fee to be charged via secure payment portal. This fee is non-refundable once the physician review has begun. Appointment scheduling will be confirmed after payment is received.

I have read and agree to all terms above. I consent to peptide therapy evaluation and authorize the $150 consultation payment.

Full legal name (electronic signature) *

Date

Start Your Wellness Journey

Complete your Form and let our experts design your personalized treatment plan.

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Peptides Coral Springs FAQs

What is the Form?

The Form is an intake form used to personalize your peptide therapy treatment plan.

Why should I complete the Form?

Completing the Form allows providers to understand your health goals and create a customized protocol.

Is the Form required?

Yes, It ensures accurate evaluation before starting therapy.

How long does Form take?

Most patients complete the Form in under 10 minutes.

What happens after submitting the form?

After submitting the Form, our team will contact you to schedule a consultation.

Is peptide therapy safe?

When guided by professionals, peptide therapy is safe and tailored to your needs.

Who reviews the Form?

Our experienced medical team reviews every Form submission.