Personal Information

First Name *

Last Name *

Date of birth *

Address *

Street Address

City

State

Postal Code

Email *

Phone *

How did you hear about our company? *

Select option

Referral
Social Media
Online Search
Other
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Please choose if you'd like to pick up your prescription(s) or have it shipped directly you. *

Pick Up (144 Thomas Green Blvd, Ste 239, Clemson SC 29631)

Shipping (I understand there is a $25 charge)

ID Verification

Patient's Photo (Take and image of yourself and upload please) *

Upload a government-issued photo ID - FRONT *

Upload a government-issued photo ID - BACK *

Demographics

Gender *

Male

Female

Gender Assigned at Birth *

Male

Female

Height (__ft __in) *

Starting Weight *

Goal Weight *

Exercise Level *

Sedentary

Moderate

Active

Your Therapy Goals Are: *

Weight Loss

Body Composition

Improve Energy / Fatigue

Improve Metabolic Health

Recovery / Performance

Reduce Inflammation

Improve Focus / Reduce Brain Fog

I am requesting to take the following products: *

Tirzepatide (GLP-1)

Semaglutide (GLP-1)

NAD+

Peptides

Peptides-Are you interested in specific peptides OR would you like to talk with the doctor about peptides?

Unsure-I Would Like to Discuss with a Doctor
NA-Not Interested
Blend-Adonix
Blend-Apex
Blend-Atlas
Blend-Bodhi
Blend-Crave
Blend-Empress
Blend-Fountain of Youth
Blend-Helios
Blend-Hyperion
Blend-Hypnes
Blend-Inferno
Blend-Kali
Blend-Kalm
Blend-Love & Happiness
Blend-Lucid
Blend-Prometheus
Blend-Samson & Delilah
Blend-Selene
Blend-Sentinel
Blend-Valkyr
Single-BPC-157
Single-MOTS-C
Single-PT-141
Single-Retatrutide
Single-Semax
Single-Sermorelin
Single-Tesamorelin
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Medical Information & History

Please list previous prescription weight loss medications such as Tirzepatide, Semaglutide, Ozempic, Mounjaro, etc *

Current Dosage if Taking Weight Loss Medication (mg/injection and how often of product is important, units varies depending on the potency of the product and does not tell us how much you are currently taking) *

If you've taken weight loss medication, when is the last time you took the medication? (1 week, months, years, etc) *

Picture of current vile(s) of the above products if applicable.

Have you ever used NAD+ supplements or injections in the past? *

Yes

No

Allergies *

Weight issues as a child? *

Yes

No

Gastric Bypass *

Yes

No

PCOS *

Yes

No

Gastric Band *

Yes

No

High Cholesterol *

Yes

No

Kidney Disease *

Yes

No

Obesity *

Yes

No

Hypertension *

Yes

No

Heart Disease *

Yes

No

Childhood Obesity *

Yes

No

Obstructive Sleep Apnea *

Yes

No

Diabetes Mellitus *

Yes

No

Are you under 18 years old? *

Yes

No

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

Yes

No

Personal or family history of medullary thyroid cancer? *

Yes

No

History of multiple neoplasia 1 or 2? *

Yes

No

History of pancreatitis? *

Yes

No

Have you been diagnosed with active cancer or received cancer treatment within the past 5 years? *

Yes

No

Have you ever been told you have congestive heart failure or severe heart disease? *

Yes

No

Do you have chronic kidney disease (stage 3 or higher) or liver failure? *

Yes

No

Are you currently taking systemic immunosuppressants or high‑dose steroids? *

Yes

No

Have you ever had a severe allergic or anaphylactic reaction to an injectable medication? *

Yes

No

Do you have untreated or unstable endocrine disorders (thyroid, adrenal, pituitary)? *

Yes

No

Have you had unexplained rapid weight loss, night sweats, or fatigue not evaluated by a physician? *

Yes

No

Do you have diabetes, high blood pressure, or another chronic condition that is not well controlled? *

Yes

No

Do you have an autoimmune disease or thyroid disorder? *

Yes

No

Are you taking hormone replacement therapy (testosterone, estrogen, thyroid)? *

Yes

No

Have you had any complications or side effects from peptide or hormone therapy before? *

Yes

No

Are you unwilling or unable to obtain basic lab before or during treatment if recommended by your provider? *

Yes

No

Sleep Hours Per Night *

Alcohol (drinks/week) *

Tobacco/Nicotine (type & frequency)

Do you currently have or have you ever been diagnosed with any of the following? (check all that apply)

Dysrhythmia, tachycardia, or atrial fibrillation

Liver cirrhosis or end-stage liver disease

Chronic kidney disease stage 3 or greater

Blood clot disorder

None of the above

Family History

Family-Diabetes *

Yes

No

Family-Heart Disease *

Yes

No

Family-Polycystic Ovarian Syndrome *

Yes

No

Family-Obesity *

Yes

No

Medications / Supplements

List all medications or dietary supplements you are currently taking (required: include dose and frequency) *

Additional Medical Conditions

List any past or current conditions, surgeries, or hospitalizations. *

Are there other medical conditions your provider should know about? *

Yes

No

List Any Additional Medical Conditions *

I Agree To

I understand peptide therapies may not be FDA-approved for all uses. *

Yes, I agree

I understand that these therapies are for wellness and optimization under medical supervision. *

Yes, I agree

I consent to an asychronous review (call/meetin unnecessary) and/or a telemedicine evaluation and treatment. *

Yes, I agree

I agree to follow dosing and monitoring instructions and report any adverse effects promptly. *

Yes, I agree

I certify that I have provided complete and accurate information to the best of my knowledge and understand that withholding or misrepresenting health information may impact efficacy and influence the clinician’s ability to determine treatment safety *

Yes, I agree