Peptide Consultation Intake

Welcome to Your Personalized Peptide Consultation

This intake helps your provider understand your health history, current concerns, medications, lifestyle, and treatment goals. Your provider will review this information as part of your consultation to determine whether additional evaluation or a provider-guided treatment option may be appropriate. Completing the intake and consultation does not guarantee that treatment or a prescription will be recommended.

A $125 consultation fee is collected when this intake is submitted. This fee covers the provider’s review of your information and your medical consultation. If you purchase an eligible peptide protocol, wellness program, or supplement in the office during your consultation, the full $125 fee will be applied toward that purchase. This credit is available only on the date of your consultation.

The consultation fee is nonrefundable, including if the provider determines that you are not an appropriate candidate for treatment. Once your appointment is scheduled, a $75 missed appointment or no-show fee will apply. Please cancel or reschedule at least 24 hours in advance.

Routine laboratory testing is not required before peptide therapy can be discussed. Your provider will let you know if any additional testing is recommended based on your health history and treatment goals.

Any treatment-specific risks, contraindications, monitoring requirements, regulatory information, and administration instructions will be reviewed separately if your provider recommends a specific treatment.

First Name

Last Name

Date of Birth

Phone

Current State of Residence.

Will your consultation be conducted in person or virtually?

In person
Virtually

Please confirm that the patient is at least 18 years old or will attend the appointment with a parent or legal guardian.

I confirm

Briefly describe your primary concern, how long it has been present, and what improvement would be most meaningful to you.

Are you currently pregnant, breastfeeding, trying to become pregnant, or planning a pregnancy?

Yes
No
Not applicable

Do you have recent laboratory results completed outside of Feel Ideal 360 that you would like Dr. Straface to review?

Laboratory results are not required for your peptide consultation. By selecting Yes, you may upload your recent labs and agree to the additional $175 comprehensive lab review fee, which includes physician interpretation and personalized recommendations.

Yes, I would like to upload my labs and add the $175 lab review. + $175.00
No, I do not need a lab review at this time.

Upload Your Labs Here

Browse (no files uploaded)

Please list your current prescription medications, injectable medications, over-the-counter medications, vitamins, and supplements. Include the dose when known.

Please list medication, food, latex, or other significant allergies and describe the reaction.

If you selected other, please describe:

Please provide details for any condition selected above, including the approximate date and whether the condition is currently active.

In the past 12 months, have you been hospitalized, had surgery, received cancer treatment, experienced a major new diagnosis, or had a serious medication reaction?

If yes, please describe:

Are you interested in a treatment specifically related to eye or visual wellness?

Do you wear:

Glasses
Contacts
Readers
No corrective lenses

Any known eye conditions, please describe:

Date of last eye exam:

Please list any current eye medications:

Please list any prior eye procedures or surgery:

I understand that the $125 consultation fee compensates the provider for reviewing my intake information and conducting my peptide consultation. The fee does not purchase medication and does not guarantee that I will qualify for peptide therapy, receive a prescription, or be recommended any specific treatment.

I agree to provide complete and accurate information regarding my medical history, current medications, injectable medications, over-the-counter products, supplements, allergies, pregnancy or breastfeeding status, and any relevant personal or family medical conditions.

I understand that withholding information or providing inaccurate information may affect my provider’s ability to evaluate me safely. Based on my history, symptoms, examination, and independent medical judgment, my provider may recommend additional laboratory testing, an in-person examination, further medical evaluation, specialist care, an alternative treatment, or no peptide treatment. If treatment is recommended, it may involve an FDA-approved medication used according to its approved labeling, an FDA-approved medication prescribed for an off-label use, or a compounded medication.

I understand that compounded medications are not FDA-approved and are not reviewed by the FDA for safety, effectiveness, or quality before they are marketed. Before beginning treatment, I will be informed of the proposed medication’s clinical purpose, regulatory status, expected benefits, reasonable alternatives, known and potential risks, limitations, monitoring requirements, and instructions, and I may be required to review and sign a separate medication-specific informed consent. I understand that individual responses and results vary and that Feel Ideal 360 and its providers do not guarantee any particular outcome.

I understand that information related to my consultation, communications, recommendations, prescriptions, and treatment will be documented in my medical record. This intake is not intended for urgent or emergency medical concerns. If I am experiencing a medical emergency, I should call 911 or seek immediate emergency care rather than submitting information through this form.

By signing below, I confirm that I have read and understand this acknowledgment, have had the opportunity to ask questions, and voluntarily consent to the consultation and medical evaluation described above.

Signature

I understand that this form is used to help direct my consultation and does not guarantee that I am a candidate for any specific treatment. I understand that treatment recommendations, if appropriate, will be based on my history, goals, exam, medical evaluation, risks, contraindications, and provider judgment.

Date

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Sub Total

$125.00

TOTAL

$125.00

Payment Method

Credit Card - Square

* By clicking “Send,” you consent to receive calls, emails, and text messages from Feel Ideal 360 at the phone number and email you provided, including via automated technology. Consent is not a condition of purchase. Message and data rates may apply.

Peptide Consultation Intake

Thank you for contacting us!