Peptide Therapy & Intake Form

Patient Information

Full name

Date of birth

Age

Height

Weight

BMI

Sex at birth

Gender identity (optional)

Phone

Primary care physician

Referring physician (if any)

Date of first appointment

Program of Interest

Peptide TherapyGLP-1 / GLP-2 / GLP-3 Receptor Agonist TherapyCombination Protocol (Peptide + GLP)Longevity & Wellness Membership

Treatment Goals & Aspirations

Weight & Metabolic History

Medical History

Contraindications & Safety Screening

Family History

Current Medications, Supplements & Allergies

Prescription medications

Supplements

Peptides currently in use

Hormones / hormone replacement therapy

Medication allergies

Food allergies

Other allergies

Lifestyle & Wellness Profile

Physical activity

Average daily steps

Average sleep (hours/night)

Typical diet

Other diet (if selected)

Follow a skincare or wellness routine?

Describe your routine

Alcohol or recreational substances?

Frequency and type

Smoking status

Current stress level

Nutrition Profile

Meals per day

Water intake (oz/day)

Protein intake (g/day)

Women's Health (if applicable)

Laboratory History

Symptoms Checklist

Patient Expectations & Acknowledgments

Please check each statement to confirm your understanding

Weight loss and treatment outcomes vary by individual and are not guaranteed.Lifestyle changes, including nutrition and exercise, are required to support optimal results.Peptide and GLP receptor agonist therapy may require long-term or maintenance use.Muscle preservation requires adequate protein intake and resistance exercise during treatment.Routine follow-up appointments and laboratory monitoring may be required throughout treatment.Dose adjustments may be needed based on clinical response and tolerability.Insurance approval and coverage, where applicable, are not guaranteed.

Consent, Safety Disclosure & Attestation

Potential side effects associated with peptide and/or GLP receptor agonist therapy include: nausea, vomiting, constipation, diarrhea, gallbladder disease, pancreatitis, dehydration, hypoglycemia (particularly when combined with insulin or sulfonylureas), possible muscle loss, and rare allergic reactions. By signing below, I confirm that the information provided is accurate and complete, and I consent to consultation with a 4everglow clinician.

How did you hear about us?

Other (if selected)

Client signature (type your full name)

Date

Strictly confidential · HIPAA-aligned handling

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Wellness, optimised. Complete your intake.