Sermorelin Intake - The Invigory

Name *

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Last

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Phone

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Home Address

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Emergency Contact

Emergency Contact Phone

Are you currently taking any medications? *

Please list medications below

Do you have any allergies to medications, foods, or other substances? *

Please specify allergies below

Do you have a history of the following (check all that apply) *

Are you currently pregnant, planning to become pregnant, or breastfeeding? *

Have you previously used peptide therapy (e.g., Sermorelin, CJC-1295, etc.)? *

When and for how long did you take Sermorelin, CJC-1295, etc?

TSH, did and

What are your primary goals for starting Sermorelin therapy? (Check all that apply) *

Other explained

Have you completed the required labs for Sermorelin therapy? (CBC, CMP, TSH, IGF-1) *

Would you like us to send you a LabCorp link to complete your labs? *

File Upload

Click or drag a file to this area to upload.

If you already have recent lab results (within 1 year), you can upload them here or email them to: RN@theinvigory.com

I confirm that the information provided above is accurate to the best of my knowledge. I understand that lab results are required prior to starting Sermorelin therapy and agree to follow the program as advised by my provider.

Signature *

By writing your name you are signing your consent.

Today's date *

26586

7314 Waverly Walk Ave
Suite E-1B
Charlotte, NC 28277
info@theinvigory.com
980.339.5826

Monday – Friday: 10am-8pm
Saturday – Sunday: 9am-6pm

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