Protocol Health - Intake Form (Female)

Protocol Health Club Intake Form - Female

Profile Information

Step 1 of 3

You are completing the following intake forms:

Protocol Health Club Female Intake Form

Please take a moment to fill out our online intake form before your telehealth visit. All information is kept completely confidential.

First Name *

Last Name *

Email *

Preferred Name (if different)

Please provide at least one phone number. Your mobile number can be used to look up your Account.

Phone *

Address

Address *

City *

State *

Country *

Postal code *

Date of birth *

Drivers License Number: *

Gender *

Male

Female

Occupation *

How Did You Hear About Us? *

Who Were You Referred To?

Did Any One Refer You to Us, and If So Who?

Questionnaire — Step 2 of 3

LET'S EMPOWER A HIGH PERFORMANCE LIFESTYLE

Why are you seeing us today? *

List what your goals are: *

Goal 1
Goal 2
Goal 3
Goal 4
Goal 5
Goal 6
Goal 7

What is the budget you're willing to invest in your health on a monthly basis? *

There is no charge associated with completing this intake form. However, after you complete the form and have your consultation, you will have the option to enroll in a Protocol Health Club Membership (if you have not done so already). If you enroll, we will take labs approximately six weeks after getting started to ensure we're on track. After the six-week labs, how often would you like to order follow-up labs to assess your health status? *

Prior Surgeries

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

CURRENT PRESCRIPTION MEDICATION

Medication 1

Name
Dosage
Times Per Day
Duration of Use

Medication 2

Name
Dosage
Times Per Day
Duration of Use

Medication 3

Name
Dosage
Times Per Day
Duration of Use

Medication 4

Name
Dosage
Times Per Day
Duration of Use

Medication 5

Name
Dosage
Times Per Day
Duration of Use

Medication 6

Name
Dosage
Times Per Day
Duration of Use

Medication 7

Name
Dosage
Times Per Day
Duration of Use

Medication Other

Current Non-Prescription Medications (Includes Herbals and Supplements)

Non-Prescription Med 1

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 2

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 3

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 4

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 5

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 6

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 7

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med Other

ALLERGIES

Allergy 1

Name
Reaction

Allergy 2

Name
Reaction

Allergy 3

Name
Reaction

Allergy 4

Name
Reaction

Allergy 5

Name
Reaction

Consents — Step 3 of 3

Protocol Health Club Male Intake Form — Consents

Accuracy of Information *

I certify that the above medical information is correct to my knowledge.

Privacy and Sharing of Information *

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confi dential andwill only be disclosed to third parties with my permission.

Messaging and Communication *

I authorize Protocol Health Club to communicate with me via SMS/text message regarding my care, appointments, and related services. I understand that SMS-based communication may not be fully secure and carries a risk of unauthorized access, but I prefer to receive communications via text message. By consenting, I acknowledge and accept these risks and release Protocol Health Club from liability related to the use of SMS communications.

Coaching Communication *

I authorize Protocol Health Club to share information regarding any peptide and/or hormone optimization products I purchase with my training and coaching team.

Blood Work *

I acknowledge that if I enroll in a membership, Protocol Health Club will charge my card $79.99 six weeks after the start of the program, and every six months thereafter for the duration of my membership. I understand that I may contact [email protected] to request blood work at increased frequency and/or additional markers for an additional cost.

Prescription Refills *

I acknowledge that if I enroll in a membership, my prescription(s) will be automatically refilled unless I indicate otherwise.

Signature *

Clear