Peptide Registration SSWC -

Name

First

Last

DOB (00/00/0000)

Phone

Drug

Email

Sex at Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

Height (feet/inches)

Current weight (lbs)

Peptide Therapy Interest

Describe your primary goals in your own words?

Any Peptide Experience (If so which one and when)? What were your results?

Health Screening

Do you have any other Medical problems?

List Past Surgeries?

Any Drug Allergies?

List all Prescription Medications (name and dose) that you currently take?

List any OTC medications and supplements?

LIFESTYLE

Average sleep hours per night

Exercise Days per week

Stress Level (1-10)

Tobacco Use

Alcohol Drinks per week

Type of exercise/activity

Have you had any Recent Lab Work (last 12 months)

yes – I can share results
yes – do not have to share
no – would like labs ordered

Please obtain a copy of your lab results and either bring to the office or fax to the office. Fax number: 317-253-7798

Consent and Acknowledgment

I understand this registration is a request for evaluation, not a prescription, and that peptide therapy requires a clinical consultation and ongoing monitoring.
I confirm I am not currently pregnant, breastfeeding, or planning pregnancy without disclosing this to Dr. Thomas.
I confirm that the information above is accurate to the best of my knowledge.

Please read carefully: Peptide therapy requires ongoing medical supervision, which may include baseline and follow-up bloodwork. Dr. Thomas will only prescribe what is appropriate for your individual case after an initial consultation and any needed labs. Many peptides are prescribed off-label and are compounded by a licensed pharmacy.

Date / Time

Date

Time

Signature (type name)