Protocol Health - 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 *

Gender *

Male

Female

Occupation

How Did You Hear About Us? *

Who Were You Referred To?

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 andhave your consultation, you will have the option to enroll in a Protocol Health Club Membership (if you havenot done so already). If you enroll, we will take labs approximately six weeks after getting started to ensurewe'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 8

Name
Dosage
Times Per Day
Duration of Use

Medication 9

Name
Dosage
Times Per Day
Duration of Use

Medication 10

Name
Dosage
Times Per Day
Duration of Use

Medication 11

Name
Dosage
Times Per Day
Duration of Use

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 8

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 9

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 10

Name
Dosage
Times Per Day
Duration of Use

Non-Prescription Med 11

Name
Dosage
Times Per Day
Duration of Use

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 Female 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

Todays Date

Protocol Health Club Intake Form - Female