Research Peptide Prescription Info - Compliance Guide

Step 01 / 05

About you

Basic details so your provider can identify and reach you.

First name

Last name

Email address

Phone number

Date of birth

Gender

Step 02 / 05

Your address

Used for prescription delivery and state licensing requirements.

Street address

City

State

Postal code

Step 03 / 05

Your treatment

What you're looking for, and a quick safety screen.

Treatment

Do any of these apply to you? Type 1 or Type 2 DiabetesHigh Blood Pressure that is uncontrolled/untreated (>150/90)History of PancreatitisHistory of Thyroid CancerNone

Step 04 / 05

Health history

Helps your provider understand what's worked before and what to watch for.

Previous weight-loss attempts

Do you experience emotional eating? YesNo

Tell us about methods you've tried before

How often do you drink alcohol?

What are you hoping to improve? (select all that apply) Improved mental clarity and focusMore EnergyBetter SleepLower Blood PressureWeight Loss

Are you currently transitioning from another GLP-1 medication? YesNo

Anything else your provider should know?

Step 05 / 05

Identity verification

Please upload clear images of the front and back of your government-issued ID.

ID Front * JPG, PNG, WEBP or PDF. Maximum 10MB.

ID Back * JPG, PNG, WEBP or PDF. Maximum 10MB.

Review & consent

Last step — please read carefully before submitting.

By submitting, your responses are sent securely to your care team for review. You'll hear back before any treatment is prescribed.