Peptide Education Call Prep

First Name*

Last Name*

Email*

Phone Number*

Date of Birth*

Gender

Height*

Weight*

Were you referred by anyone?

Occupation

Have you ever used peptides before?

Yes

Do you have any pre-existing medical conditions?

Do you have a history of cancer?

Do you have a family history of cancer?

Please list the supplements you are currently taking.*

Please list the medications you are currently taking.*

Please list any allergies or sensitivities to food, supplements, animals or chemicals.*

Have you had any recent hospitalizations? If so, please explain.*

How many hours of sleep do you typically get per night?*

Do you consume alcohol?*

Do you use tobacco or nicotine products?*

Yes

What is your current activity level?*

On a scale of 1 to 10 (1 = No Stress, 10 = Extremely High Stress), how would you rate your current stress level?*

Do you have any weight concerns? If so, how much weight would you like to lose or gain?

Do you follow a specific diet or nutrition plan? If yes, please describe.

Do you have any food preferences or restrictions (gluten free or vegetarian for example).

Do you consent to a Peptide Consultant and our AI reviewing your submitted information to create a personalized, research-based wellness plan?*

Yes

Do you have up-to-date bloodwork completed within the last 3 months?*

Yes, I have current bloodwork and will send it prior to my coaching call. If anything is missing, I will complete the necessary tests beforehand.

No, I still need to complete my bloodwork and will do so before the coaching call.

What are your health and wellness goals?

Anything else you'd like to share!

LOOP is committed to protecting and respecting your privacy, and we'll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you:

I agree to receive other communications from LOOP.

Consent & Liability Waiver

By submitting this intake form, I acknowledge, understand, and agree to the following:

Informational Use Only:
I understand that Loop Health & Wellness LLC is not a licensed medical provider and does not offer medical advice, diagnosis, or treatment. All services, content, and communications are for informational and educational purposes only. Nothing provided by LOOP is intended to replace consultation with a licensed healthcare professional.
Personal Responsibility & Risk:
I take full and sole responsibility for all decisions related to my health, wellness, and use of any information or services provided by Loop Health & Wellness. I agree to consult a qualified medical provider before beginning any new wellness protocol, including supplements, peptides, or lifestyle changes.
Research-Use Only Disclaimer:
I acknowledge that peptides referenced or discussed by Loop Health & Wellness are for research use only, have not been evaluated by the FDA, and are not approved for human consumption. I voluntarily assume all risks associated with their purchase, possession, or use, and release Loop Health & Wellness from any and all liability, including for side effects or adverse reactions.
Bloodwork and AI-Generated Insights:
If I choose to submit lab results, I authorize Loop Health & Wellness to process them using AI-powered tools to generate educational insights. I understand these insights are not medically validated or intended to diagnose or treat any condition. I acknowledge that LOOP does not interpret bloodwork for clinical or diagnostic use, and I accept all responsibility for how I use or act on this information.
Release of Liability:
I expressly waive, release, and discharge Loop Health & Wellness LLC, its officers, employees, contractors, and affiliates from any and all claims, demands, damages, or liabilities arising from my participation in its programs, use of peptides, or reliance on any information provided through its services — including but not limited to errors, omissions, or the use of AI-generated insights.

By clicking submit, I confirm that I have read this waiver in full and agree to all terms. I consent to Loop Health & Wellness storing and processing my submitted information for the purpose of providing the services requested.

Welcome to Your Peptide Education Call Prep!

Consent & Liability Waiver