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Peptide Therapy Registration Form

Peptide Therapy Program

Peptide Therapy Registration

For patients interested in peptide therapy at Sure Success Wellness Center. This registration gives Dr. Thomas the information she needs to determine whether peptide therapy is safe and appropriate for you, and to design a personalized protocol.

3077 E. 98th Street, Suite 190, Carmel, IN 46280  |  (317) 253-7795  |  [email protected]

🔒 Submissions are sent to Dr. Thomas’s clinical team by email. Registration is a request for evaluation, not a prescription — a consultation is required before any peptide can be prescribed. Please avoid including details you would prefer not to send by standard email; you may leave a field blank and share it with us by phone.
Identity and Contact
Peptide Therapy Interest

Select any you’d like to discuss. Dr. Thomas will confirm what is appropriate for you.

Goal Priority

How much is each area affecting you right now? Rate 0 (not a concern) to 4 (major concern).

0 = Not a concern4 = Major concern
Weight and body composition
Energy and fatigue
Injury, recovery, or joint pain
Sleep quality
Health Screening

Please check anything that applies to you (personal or family history):

Current Medications and Supplements
Lifestyle Baseline
Recent Lab Work

Have you had recent (within 6 months) lab work?

Consent and Acknowledgment
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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.
Signature
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Registration Submitted

Your email client should have opened with your responses ready to send to Dr. Thomas’s team.

If nothing happened, please email your form directly to [email protected] or call us at (317) 253-7795.

A member of our team will reach out within one business day to schedule your consultation.