RX GLEAM PLLC · Patient Intake

Peptide Therapy Intake

Complete this packet to request peptide therapy. Our licensed physician reviews every submission within 24 hours.

LegitScript Certified·U.S. Licensed·HIPAA Aware

1
Personal Info
2
Medical History
3
Screening
4
Product Selection
5
Consents
6
Sign & Submit

Step 1 of 6

Personal Information

All information is kept strictly confidential.

Full Legal Name*Preferred NameDate of Birth*Sex Assigned at Birth*

MaleFemale

Street Address*

City*State (for licensure)*ZIP*

Primary Phone*Alternate PhoneEmail*

Emergency Contact

Name*RelationshipPhone*

Primary Care Physician (optional)

Physician NamePractice / ClinicPhone

Preferred Pharmacy (optional)

Pharmacy NamePhoneAddress

How did you hear about us?

Your information is encrypted in transit (HTTPS) and stored in compliance with HIPAA. The signed intake packet is sent to your physician at support@rxgleam.com and a copy emailed to you. Questions? support@rxgleam.com

Peptide Therapy Intake

Personal Information

Emergency Contact

Primary Care Physician (optional)

Preferred Pharmacy (optional)

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