Peptide Prescription Intake

Personal information

Enter your legal name and contact details exactly as they appear on your government-issued ID.

Fields marked * are required. Your information is transmitted securely and handled in accordance with HIPAA.

Legal first name *

Legal last name *

Date of birth *

Sex assigned at birth *

Height / Weight

Contact

Email address *

Phone number *

Florida address *

Must be a Florida address. Fla. Stat. §456.47 requires patients to be in Florida at time of telehealth consult.

Identity verification

Government-issued ID type *

ID number *

Used only for identity verification as required under Florida telehealth law. Not stored after verification.

Telehealth & privacy consents

Florida law requires your informed consent before telehealth services may be provided. Please read each section carefully.

All three consents below are required before a provider can review your intake. Controlled substances (Schedule II-V) cannot be prescribed via telehealth without a prior in-person exam under Florida law.

Electronic signature

Full legal name (e-signature) *

By typing your name you apply a legally binding electronic signature under UETA and the federal E-SIGN Act.

Today's date *

Treatment goals

Tell us what you're hoping to achieve. This helps the provider tailor your prescription.

Primary treatment goal(s) — check all that apply

Weight loss / body composition Muscle building / recovery Anti-aging / longevity Energy & vitality Hormone optimization Sleep improvement Skin health / aesthetics Immune support Other

Describe your goals in your own words

Have you used peptide or hormone therapies before?

Yes No

If yes, which therapies and how long ago?

Have you had labs done in the past 12 months? (testosterone, hormones, metabolic panel)

Yes No Not sure

If yes, what were the key findings or concerns?

Health conditions

Check all current or past conditions. This allows the provider to screen for contraindications and adjust your prescription accordingly.

Cardiovascular

Long QT syndrome / QTc prolongation Cardiac arrhythmia (any type) Hypertension Heart failure

Endocrine & metabolic

Diabetes (type 1 or 2) Thyroid disorder (hypo or hyperthyroid) Adrenal insufficiency G6PD deficiency Active or recent cancer (past 5 years)

Reproductive & hormonal

Prostate cancer or elevated PSA (men) Polycystic ovary syndrome (PCOS) Hormone-sensitive tumors (breast, uterine) Hypogonadism (diagnosed)

Gastrointestinal & renal

Liver disease / cirrhosis Chronic kidney disease Currently on dialysis IBD (Crohn's / ulcerative colitis) History of GI bleeding

Neurological & psychiatric

Seizure disorder / epilepsy Psychiatric condition (depression, anxiety, bipolar, etc.) History of eating disorder

Immune & other

Immunocompromised (HIV, transplant, chemo) Prior anaphylaxis (any cause) Sleep apnea (diagnosed) None of the above

Reproductive health

Are you currently pregnant or trying to become pregnant? *

Yes No Not applicable

Are you currently breastfeeding?

Yes No Not applicable

Are you using oral contraceptives or hormonal birth control?

Yes No

Surgical & hospitalization history

Any hospitalizations or surgeries in the past 12 months?

Yes No

Date of last physical exam

Medications & allergies

Accurate allergy and medication information is critical for safe prescribing.

The allergies below are directly relevant to peptide and hormone therapies. Check all that apply — each triggers a provider review before prescribing.

Drug allergies

Describe any allergic reactions — type and severity

Any other drug, food, or environmental allergies

Current prescription medications

List all current prescription medications, doses, and frequencies

Any antibiotics taken in the past 3 months?

Yes No

OTC medications & supplements

Regular OTC medications

Vitamins and supplements

Are you taking any blood thinners? (warfarin, Eliquis, Xarelto, Plavix)

Yes No

Peptide-specific screening

These questions target specific contraindications for peptide and hormone therapies. Answering “yes” flags your intake for closer provider review — it does not automatically disqualify you.

GLP-1 screening (Semaglutide / Tirzepatide)

GLP-1 agonists are contraindicated in patients with a personal or family history of medullary thyroid carcinoma or MEN2 syndrome.

Personal or family history of medullary thyroid carcinoma (MTC)?

Yes No Not sure

Diagnosed with Multiple Endocrine Neoplasia type 2 (MEN2)?

Yes No Not sure

Personal or family history of pancreatitis?

Yes No

History of gallbladder disease?

Yes No

Diagnosed with gastroparesis or severe GI motility disorder?

Yes No

Testosterone / hormone screening

Have you ever been diagnosed with prostate cancer, breast cancer, or a hormone-sensitive tumor?

Yes No

Have you had a testosterone or hormone panel done in the past 12 months?

Yes No Not yet

Do you have polycythemia (high red blood cell count) or a history of blood clots (DVT, PE)?

Yes No Not sure

Are you currently taking any erectile dysfunction medications? (sildenafil, tadalafil)

Yes No

Growth hormone / Sermorelin screening

Have you been diagnosed with active cancer or a tumor within the past 5 years?

Yes No

Do you have carpal tunnel syndrome, or have you experienced significant joint swelling?

Yes No

Do you have acromegaly or gigantism?

Yes No

NAD+ screening

Do you have active cancer currently being treated?

Yes No

History of migraines or severe headaches after IV infusions?

Yes No

Additional notes

Anything else the prescribing provider should know

Do you have a primary care physician?

Yes No

If yes, provider name and practice (optional, for records coordination)

Delivery & emergency contact

Your prescription will be dispensed and shipped directly by D&D Pharmacy to the Florida address you provided.

Delivery preference

Ship to me

Delivered to the Florida address on file. Ships within 1 business day once authorized.

In-store pickup

Pick up at 9787 SW 72nd St, Miami. Ready within 24 hrs of authorization.

Emergency contact

Emergency contact name

Relationship

Emergency contact phone

Select your peptides

Choose the products you'd like included in your first prescription. Your provider will confirm clinical appropriateness during review.

You can select multiple products. Your provider may adjust quantities based on your health profile. A $30 prescription fee will be added to your first order total.

Subtotal$0.00

Prescription fee$30.00

Grand total$30.00

Review & submit

Please review your information before submitting. A licensed Florida provider will evaluate your responses and contact you within 1 business day.

Start your peptide prescription.

Do you have an active peptide prescription with D&D Pharmacy?

Select your peptides

Your information

Review your order

Order submitted

Personal information

Telehealth & privacy consents

Treatment goals

Health conditions

Medications & allergies

Peptide-specific screening

Delivery & emergency contact

Select your peptides

Review & submit

Submitted successfully

What to expect

Privacy & security

Questions?

Florida telehealth notice