Sermorelin - Intake Form

1
The information you provide is treated with the utmost confidentiality and will be reviewed by a registered clinician. These questions help the prescriber make an informed decision about whether treatment is suitable.
2
Which state do you currently live in?* This field is required.NOTE: We currently only serve the following four states. More states coming soon!
Florida
Texas
Arizona
Minnesota
Another US state OR Outside the USA
3
We currently only serve Florida, Texas, Arizona, and Minnesota. You MUST be located in one of those four states to use our service.
4
"I confirm that I am 25 years of age or older."
YESNO
5
We do not offer sermorelin to patient under 25 years of age.
6
What sex were you registered with at birth?* This field is required.
Male
Female
7
Are you currently pregnant, breastfeeding or planning to become pregnant soon?* This field is required.
Yes
No
8
Your response suggests that this medication may not be appropriate for online purchase.
9
Pregnancy/Breastfeeding Consent* This field is required.Please review and agree to the following breastfeeding/pregnancy precaution. Please read the following for more information about this product and its potential side effects. Pregnancy and Breastfeeding precautions: The FDA says that these medications may pose a risk to the developing fetus (baby) if you get pregnant while taking them. "The pill" (oral contraception) is not enough because this medication can interfere with its effectiveness. For birth control, you must use condoms, an IUD, or an implanted device. Official FDA recommendation: For the first month after first starting a weight loss medication, and for the first month after each dose escalation, continue using your oral contraception and add a barrier method of contraception (such as condoms) to prevent pregnancy. Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before starting your medication. When you stop the medication, you must continue using a backup method (like condoms) for two months after stopping to allow the medication to entirely leave your system before getting pregnant. Similarly, it is not known to be safe in breastfeeding. If you are breastfeeding, consult your doctor for safe weight-loss options. CLICK YES IF you Consent.
Yes
No
10
Your response suggests that this medication may not be appropriate for online purchase.
11
Do you have any medical conditions?* This field is required.
Yes
No
12
Tell us more about your medical conditions.* This field is required.
13
Are you currently taking any medications?* This field is required.
Yes
No
14
Please list all your current medications including dosages.* This field is required.
15
Do you have any known allergies?* This field is required.
Yes
No
16
Please list all of your known allergies.* This field is required.
17
What is your weight?* This field is required.
Provide your weight in pounds.
18
Height (in feet and inches)* This field is required.
19
Do you have any of the following symptoms?* This field is required.Presence of one or more of the following symptoms may make you a good candidate for sermorelin.
Fatigue
Weight Gain
Sleeping Difficulties
Reduce muscle mass
Poor Endurance
Muscle Weakness
Low Energy
Chronic Fatigue
Brain Fog
Lack of Focus
Low libido
None of the above
20
Have you had any injuries or surgeries within the last 6 months?* This field is required.
Yes
No
21
Please describe the surgery or injury and approximate date.* This field is required.
22
Any known history of B-12 deficiency or absorption issues?* This field is required.
Yes
No
23
Please tell us more about your B-12 history* This field is required.
24
Please tell us if any digestive conditions such as Crohn's disease or celiac disease may affect B12 absorption.* This field is required.
25
Do any of the following apply to you?* This field is required.
Hypothyroidism
Glioma
Any other type of cancer or tumor
None of the above
26
If you have hypothyroidism, this should be controlled PRIOR TO starting Sermorelin.
27
If you have a current or previous Glioma, you are NOT eligible for Sermorelin as your unique condition poses a safety risk.
28
If you have any type of cancer currently, or in remission, you have a unique risk that is not present in those without cancer; you should not take Sermorelin
29
Do you take any of the following medications?* This field is required.
Clonidine or Levodopa
Octreotide, lanreotide, or pasireotide
Glucocorticoids (such as prednisone, dexamethasone)
COX inhibitors (Aspirin, Advil, Celebrex, or similar)
None of the above
30
Unfortunately, you are likely NOT a candidate for sermorelin through this platform, due to your specific medication history.
31
Please select all that apply* This field is required.
I binge drink (4 or more alcoholic drinks at one time)
I take opiates (prescription or recreational)
Both apply to me
NONE of this applies to me
32
Unfortunately, you are likely NOT a candidate for sermorelin through this platform, due to your alcohol and/or opiate usage.
33
When was the last time you had an in person medical evaluation including laboratory tests?* This field is required.
Less than a year ago
1 to 2 years ago
More than 2 years ago
34
Unfortunately, you are likely NOT a candidate for sermorelin through this platform, due to your lack of recent medical evaluation.
35
Please introduce yourself and share any other information about yourself and your health that you would like to.* This field is required.
36
Before you provide your payment information, note that you are NOT charged until and unless the doctor has approved your application and is ready to send your prescription to the pharmacy.
37
Enter Your Payment Information* This field is required.You are NOT charged until and unless the doctor has approved your application and is ready to send your prescription to the pharmacy.
prevnext( X )
Sermorelin | Nasal Spray | Renewing 1-Month Supply
Potent, pharmacy‑compounded sermorelin that supports natural HGH signaling. Prepared by a licensed U.S. compounding pharmacy and delivered in a simple, needle‑free spray for precision‑guided nightly use.
$199.00 for each month
SUBSCRIBE
Email
First Name
Last Name
38
Shipping Address* This field is required.This is where we'll be sending your sermorelin (if approved)! Enter accurately.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
39
Phone Number* This field is required.
Area Code
Phone Number
40
Provide your name for the prescription* This field is required.Must be legally accurate.
First Name
Last Name
41
Provide your date of birth for the prescription.* This field is required.Must be legally accurate.
Date
Year
Month
Day
42
Provide an accurate email to receive updates on your prescription.* This field is required.
example@example.com
43
Please review the following HIPAA notice of privacy practices before continuing:

NOTICE OF PRIVACY PRACTICES

Please review the following telehealth informed consent before continuing:

TELEHEALTH INFORMED CONSENT

Please review the following consent and disclosures document before continuing:

CONSENT AND DISCLOSURES

Next, you will be asked to sign, indicating your full acknowledgement of, understanding of, and agreement to these three documents.
44
Consent & Acknowledgment Signature* This field is required.By signing below, I confirm that I understand and agree to (1) the Notice of Privacy Practices document, (2) the Telehealth Informed Consent Document, and (3) the Consent and Disclosures document. My signature is also an agreement that the information provided herein is accurate and I consent to all policies, treatment, and privacy practices of this service.
Clear
Should be Empty: