CLIENT INTAKE

Health questionnaire,
consent & waiver.

Please complete every section. Your information is reviewed confidentially by our medical team before any protocol is recommended.

CLIENT INFORMATION

FULL NAME *DATE OF BIRTH *PHONE NUMBER *EMAIL ADDRESS *EMERGENCY CONTACT (NAME & PHONE) *PRIMARY CARE PHYSICIAN

PAST MEDICAL HISTORY

Select all that apply

ADDITIONAL MEDICAL HISTORY / NOTES

CURRENT MEDICATIONS & ALLERGIES

CURRENT MEDICATIONS / SUPPLEMENTSKNOWN ALLERGIES

LIFESTYLE & WELLNESS

Select all that apply

INFORMED CONSENT

I understand that peptide therapies and/or research compounds may carry known and unknown risks. I acknowledge that some compounds may not be FDA-approved for the intended use discussed. I understand that individual results vary and that no guarantees have been made regarding outcomes. I agree to disclose all relevant medical history truthfully.

LIABILITY WAIVER

I voluntarily assume all risks associated with participation in wellness, peptide, and/or research compound protocols discussed or provided by HACK Performance Labs. I release and hold harmless HACK Performance Labs, its physicians, nurses, staff, contractors, and affiliates from claims or liabilities arising from undisclosed medical conditions, misuse, failure to follow instructions, or unforeseen reactions.

SIGNATURE

TYPE YOUR FULL LEGAL NAME AS SIGNATURE *DATE *

OR DRAW YOUR SIGNATURE (OPTIONAL)

DRAW SIGNATURE ABOVE

By submitting, you certify that the information provided is true and complete to the best of your knowledge.

REVIEWED BY LICENSED CLINICIANS

Health questionnaire,consent & waiver.