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Foundations Intake Form
Patient Information
First Name
Last Name
Phone Number
Email Address
Basic Health History
Please provide a brief overview of your general health history (diagnoses, past issues, significant past treatments):
Family Medical History (as relevant to peptide use)
Please list any significant family medical history such as diabetes, heart disease, cancers, autoimmune conditions, hormone disorders:
Medications & Allergies
Current Medications:
Medication or Other Allergies:
Current Complaint / Health Goals
Please describe your current symptoms, concerns, or goals you wish to achieve through the Foundations Program (weight loss, performance, recovery, hormone balance, etc.):
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