Submit an application online via our portal or visit our office with necessary identification.

Both parties must present a valid ID such as a driver's license or passport. Proof of age and residency may also be required. For a complete list of requirements, visit our website.

Standard processing time is 2-3 weeks. Expedited service options are available for faster delivery within 5-7 business days.

Yes, BeWELL GetStarted offers digital access to various historical records. Some records may require a small fee for access to detailed documents.

No, there is no limit on the number of copies one can request. Each certified copy is subject to a standard fee.

Our office is open from 9:00 AM to 5:00 PM, Monday through Friday. We are located at [Insert Address Here].

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Please complete all questions accurately and completely. Your answers are used to identify conditions that may require additional evaluation, laboratory testing, specialist clearance, treatment .modification, or deferral before peptide therapy is considered

Legal first name *

Legal last name *

Date of Birth *

Age *

Sex *

Female

Male

Address *

City *

State *

ZIP *

Mobile Phone *

Email *

Primary Care Provider

PCP Phone

Do you have any medication allergies? *

Yes

If yes, list medication and reaction:

Have you ever had an allergic or serious reaction to an injectable medication? *

Yes

Have you ever had an allergic or serious reaction to a peptide, compounded medication, bacteriostatic water, benzyl alcohol, or injectable medication ingredient? *

Yes

Unsure

Do you carry an epinephrine auto-injector for severe allergies? *

Yes

Reason for seeking peptide therapy *

Weight management or fat loss

Exercise performance

Joint, tendon, or soft-tissue support

Sleep

Skin health or appearance

Healthy aging or longevity

Immune support

Muscle development or body composition

Recovery from exercise or injury

Energy

Cognitive performance or focus

Hair health

Sexual wellness or libido

Other

Other:

Primary concerns or goals:

Have you experienced any significant unexplained change in your health during the past 6 months? *

Yes

Have you experienced unexplained weight loss? *

Yes

Unexplained or persistent fever? *

Yes

Persistent night sweats? *

Yes

Unexplained severe fatigue or weakness? *

Yes

New or unexplained lumps, masses, swollen lymph nodes, or persistent swelling? *

Yes

Unexplained bleeding or bruising? *

Yes

New or unexplained neurological symptoms? *

Yes

If YES to any question above, explain:

Alcohol use: *

None

Occasional

Weekly

Daily

Approximate drinks per week:

Have you EVER been diagnosed with cancer, leukemia, lymphoma, melanoma, or another malignancy? *

Yes

Type of cancer / malignancy:

Year diagnosed:

Date treatment completed:

Treatment received:

Surgery

Chemotherapy

Radiation

Immunotherapy

Hormonal therapy

Other

Other:

Is the cancer currently active or being treated?

Yes

Current status:

Cancer-free / remission

Active disease

Under surveillance

Unsure

Have you ever had a recurrence or metastatic cancer?

Yes

Are you currently followed by an oncologist?

Yes

Have you ever had a precancerous condition, abnormal tumor marker, abnormal biopsy, or lesion requiring surveillance? *

Yes

If yes, explain:

Have you ever had melanoma? *

Yes

Have you ever had another type of skin cancer? *

Yes

If yes, type:

Do you currently have a mole or skin lesion that is new, changing, irregular, bleeding, itching, rapidly growing, or not medically evaluated? *

Yes

Have you ever had an abnormal or dysplastic mole requiring biopsy or monitoring? *

Yes

Do you currently see a dermatologist for mole or skin-cancer surveillance? *

Yes

Cardiovascular history *

High blood pressure

Coronary artery disease

TIA or mini-stroke

Peripheral vascular disease

Atrial fibrillation

Heart rhythm abnormality or arrhythmia

Uncontrolled high blood pressure

Heart failure

Blood clot or DVT

Other heart or vascular disease

Heart attack

Cardiomyopathy

Stroke

Pulmonary embolism

None of the above

Do you currently experience chest pain, unexplained shortness of breath, fainting, significant palpitations, or unexplained swelling of your legs or feet? *

Yes

Endocrine, pituitary and hormonal history *

Pituitary tumor or pituitary disease

Acromegaly

Elevated growth hormone

Thyroid disease

Thyroid cancer

Cushing syndrome

Other endocrine or hormonal disorder

Hypothalamic disorder

Growth-hormone disorder

Elevated IGF-1

Thyroid nodule

Adrenal disorder

PCOS

None of the above

Have you ever had pituitary surgery, pituitary radiation, head radiation, or a significant traumatic brain injury affecting pituitary function? *

Yes

Have you ever been told your IGF-1 was elevated? *

Yes

Never tested

Are you currently pregnant? *

Yes

Not applicable

When was your last menstrual period? (If applicable)

Are you currently breastfeeding? *

Yes

Not applicable

Are you actively trying to become pregnant? *

Yes

Not applicable

Is there any possibility you could currently be pregnant? *

Yes

Not applicable

Are you currently receiving fertility treatment? *

Yes

If yes, explain:

Kidney and liver history *

Chronic kidney disease

Recurrent kidney stones

Hepatitis

Persistently elevated liver enzymes

Kidney failure

Abnormal kidney function

Cirrhosis

Other kidney or liver disease

Dialysis

Fatty liver disease

Liver failure

None of the above

If yes, explain:

Diabetes and metabolic history *

Type 1 diabetes

Insulin resistance

Hypoglycemia

Type 2 diabetes

Metabolic syndrome

Hyperlipidemia or high cholesterol

Prediabetes

Gestational diabetes

None of the above

Most recent A1c, if known:

Date:

Do you currently use insulin or diabetes medication? *

Yes

Have you recently experienced excessive thirst, frequent urination, unexplained weight loss, or unusually high blood glucose readings? *

Yes

Neurological and psychiatric history *

Seizure disorder or epilepsy

Stroke

Psychotic disorder

Severe insomnia

Unexplained seizure

Bipolar disorder

Severe or uncontrolled anxiety

Other significant neurological or psychiatric condition

Traumatic brain injury

Mania or hypomania

Severe depression

None of the above

Have you experienced a seizure within the past 12 months? *

Yes

Not applicable

Autoimmune and immune system history *

Lupus

Hashimoto's thyroiditis

Ulcerative colitis

Ankylosing spondylitis

Graves' disease

Psoriasis or psoriatic arthritis

Other autoimmune disease

Rheumatoid arthritis

None of the above

Condition(s):

Current control:

Controlled

Uncontrolled

Unsure

Are you taking steroids, biologics, immunosuppressants, chemotherapy, or other immune-modifying medication? *

Yes

If yes, list:

Have you EVER received an organ or bone-marrow transplant? *

Yes

Do you currently have an active infection? *

Yes

Are you currently taking antibiotics, antivirals, or antifungal medication for an infection? *

Yes

Do you currently experience persistent swelling or fluid retention in your hands, feet, ankles, or legs? *

Yes

Have you been diagnosed with carpal tunnel syndrome? *

Yes

Do you currently experience unexplained numbness or tingling in your hands or feet? *

Yes

Write “None” if you take nothing.

List ALL prescription medications, over-the-counter medications, hormones, injections, supplements, vitamins, herbal products, and weight-loss medications currently being used. *

Have you had laboratory testing done in the past 12 months? *

Yes

Unsure

If yes, list any abnormal results and date, if known:

Have you had IGF-1 testing done? *

Yes

Unsure

Result/date:

Have you had a recent physical exam within the past 12 months? *

Yes

Unsure

Current or previous peptide and hormone use

BPC-157

Sermorelin

KPV

Epitalon

Kisspeptin

TB-500

Tesamorelin

LL-37

Semax

Thymosin Alpha-1

CJC-1295

AOD-9604

MOTS-C

Selank

GLP-1 medication

Ipamorelin

GHK-Cu

NAD+

Melanotan II

Other

Other:

Did you experience any adverse effects?

Yes

If yes, describe:

Have you been advised by another healthcare provider NOT to use growth hormone, peptides, hormone therapy, GLP-1 medications, or similar treatments? *

Yes

Are you currently undergoing evaluation for an unexplained medical condition or abnormal laboratory result? *

Yes

Have you had abnormal laboratory results during the past 12 months that have not been evaluated or explained? *

Yes

Is there anything about your medical history, symptoms, medications, supplements, or previous treatments that the provider should know before considering peptide therapy? *

Yes

If yes, please explain:

Photo ID *

Click to upload

Patient Certification and Acknowledgment

By signing below, I certify that the information I have provided in this Medical Intake Form is true, accurate, and complete to the best of my knowledge. I understand that this information may be used by my healthcare provider and authorized members of the care team to evaluate my health, determine my eligibility for services, and assist in making decisions regarding my care.

I understand that withholding information or providing inaccurate or incomplete information may affect the provider's ability to appropriately evaluate or provide services to me. I agree to notify my healthcare provider of any significant changes to my health, medical history, medications, allergies, or other information provided on this form.

I acknowledge that I have had the opportunity to review the information provided before signing and that I understand the purpose of this Medical Intake Form. My signature below confirms that the information provided is accurate and complete to the best of my knowledge.

Today's Date: 09/14/2026

Signature *

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Your medical intake

Patient Certification and Acknowledgment