Patient Intake Form - Serenity Glow & Wellness

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About You

Basic contact details so we can reach you

FIRST NAME*

LAST NAME*

Date of Birth*

MM slash DD slash YYYY

BIOLOGICAL SEX*

EMAIL ADDRESS*

PHONE NUMBER*

STATE*

HOW DID YOU HEAR ABOUT US?

Preferred Consultation Type

Your Goals

Tell us what you want to work on — select everything that applies

Select all that apply. Most patients come to us with more than one concern — we build protocols that address everything together.

WHAT BRINGS YOU TO US TODAY?

FERTILITY — TTC, egg quality, IVF prep, PCOS

WEIGHT LOSS — fat loss, appetite control

LOW ENERGY & FATIGUE — chronic exhaustion

HEALTHY AGING — longevity, skin, vitality

METABOLIC HEALTH — blood sugar, insulin resistance

BRAIN FOG — focus, memory, mental clarity

RECOVERY & PERFORMANCE — strength, healing

INFLAMMATION — joint pain, immune support

STRESS & HORMONES — cortisol, sleep, balance

SKIN REJUVENATION — anti-aging topicals

HORMONAL IMBALANCE — perimenopause, cycles

MEN'S HEALTH — testosterone, male fertility

DESCRIBE YOUR MAIN CONCERN IN YOUR OWN WORDS*

HOW LONG HAVE YOU BEEN DEALING WITH THIS?*

WHICH PROGRAM INTERESTS YOU MOST?

Health Snapshot

Current medications, diagnoses, and allergies — kept strictly confidential

Current Medications

ARE YOU ON ANY PRESCRIPTION MEDICATIONS?

KNOW HEALTH CONDITIONS*

Select any conditions you have been diagnosed with or suspect:

Thyroid disorder (hypo / hyper / Hashimoto's)

PCOS

Insulin resistance

Type 2 diabetes / pre-diabetes

Autoimmune condition

Antiphospholipid syndrome (APS)

Heart disease / cardiovascular

High cholesterol / triglycerides

High blood pressure

Cancer history

Endometriosis

Anxiety / depression

Osteoporosis / bone density concerns

No known diagnoses

ANY OTHER DIAGNOSES TO SHARE? (optional)

ALLERGIES

KNOWN ALLERGIES TO MEDICATIONS, FOODS OR SUPPLEMENTS

LIFESTYLE QUICK CHECK

EXERCISE FREQUENTLY

AVERAGE SLEEP PER NIGHT

ALCOHOL USE

SMOKING / TABACCO

ANYTHING ELSE WE SHOULD KNOW (optional)

Consent & Signature

Almost done — just a few agreements and your signature

Please read and acknowledge each item below. All are required except the last one.

Consent*

Medical Disclaimer: I understand that all peptide protocols require a valid prescription from a licensed provider. These services are not a substitute for emergency medical care. These statements have not been evaluated by the FDA.

Compounding Pharmacy: I understand medications are compounded by licensed 503A/503B pharmacies and that results vary by individual. Prices are for medication only and consultation fees are separate.

Telehealth Consent: I consent to receive care via telehealth video or phone consultation through Serenity Glow & Wellness.

Privacy & HIPAA: I acknowledge that my health information will be kept confidential and handled in accordance with HIPAA regulations. I consent to being contacted at the phone number and email I provided.

Marketing (Optional): I agree to receive wellness tips, protocol updates, and program information via email. I may unsubscribe at any time.

ELECTRONICS SIGNATURE - TYPE YOUR FULL NAME*

By typing your name you are electronically signing this intake form and confirming all information is accurate to the best of your knowledge.

TODAY'S DATE*