New Membership Intake Form | Eternal Longevity

Personal Information

Full Name

Date of birth

Email *

Sex at Birth *

Phone *

Address

Street Address *

City *

State *

Emergency Contact Name *

Emergency Contact's Phone *

Emergency Contact's Email *

Referring Physician / Referral Source

Current Medications

Please include the name of the medication, Dose, and Frequency. Example: Metformin - 500 mg - Twice daily

Prior Peptide Use?

Wellness Goals

Other:

Informed Consent & Authorization

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others.from Eternal Hair at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

I confirm that the information provided above is accurate and complete to the best of my
knowledge. I understand that peptide therapies are for research purposes only, and that I am
solely responsible for my health decisions. I acknowledge that I have read and understood all
instructions provided, and I consent to my intake information being reviewed by the Eternal
Longevity team for the purpose of peptide protocol recommendations.

By signing below, I confirm that I am not currently pregnant, breastfeeding, or under the care

of a physician who has advised against peptide therapy.

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ETERNAL LONGEVITY

New Member Intake Form

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This form is confidential

Personal Information

Medical History

Current Medications

Wellness Goals

Informed Consent & Authorization