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Patient Intake Submissions
New Member Screening
Quick Intake Before You Browse
Takes about 2 minutes. Your information is strictly confidential and used only to verify eligibility.
🔒 Private & confidential
✓ No typing required for most questions
⚡ ~2 minutes to complete
Step 1 of 6
Who are you?
Just the basics — we keep this private.
Male
Female
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Prefer not to say
Step 2 of 6
Any medical history?
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Heart disease
Diabetes
High blood pressure
Liver disease
Kidney disease
Thyroid disorder
Cancer history
Autoimmune
Blood clotting
Hormonal imbalance
Seizures
Stroke / TIA
Psychiatric
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Drug/peptide allergy
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Step 3 of 6
Current medications?
List anything you take — prescriptions, supplements, hormones. Skip if none.
Step 4 of 6
What are your goals?
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Anti-aging
Weight loss
Performance
Better sleep
Cognition
Immune support
Skin / Healing
Libido
Joint recovery
Gut health
Hair growth
Energy
No
Yes
Step 5 of 6
Consent & Disclaimer
Tap each box to confirm. Tap "Agree to all" to accept at once.
All information I provided is accurate and complete to the best of my knowledge.
I consent to my intake being reviewed by the Eternal Longevity team for peptide recommendations.
I understand this is for informational purposes only and does not constitute medical advice.
I understand results may vary and voluntarily accept risks associated with peptide therapy.
I release Eternal Longevity from liability arising from my use of peptide therapy services.
I am at least 18 years of age and legally competent to provide this consent.
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Private Catalog — Authorized Clients Only
Precision Peptide Protocols
Pharmacy-grade peptides, independently third-party tested for purity, potency, and sterility. Available exclusively to trusted clients.
50+
Products
100%
3rd Party Tested
Discreet
Packaging & Fulfillment
GLP-1 & Weight Loss
Semaglutide, Tirzepatide, Retatrutide, AOD-9604 and advanced compounded formulas for metabolic support.
Healing & Recovery
BPC-157, TB-500, GHK-CU, NAD+ and expertly curated tissue repair and recovery stacks.
Growth & Performance
CJC-1295, Ipamorelin, IGF-1 LR3, Tesamorelin and GH secretagogue stacks for peak performance.
Cognitive & Longevity
Epithalon, Selank, Semax, Thymosin Alpha-1, Pinealon and immune-modulating longevity protocols.
All Products
Reconstitution & Dosing Guide
Step-by-step visual guide for safely reconstituting and injecting your peptides. Follow each step precisely for best results and safety.
Universal Reconstitution Protocol
1
Remove caps from both vials. Wipe rubber stoppers with alcohol swabs and allow to air-dry 30 seconds.
2
Draw the exact volume of bacteriostatic water specified in the product guide below into a clean insulin syringe.
3
Inject BW slowly down the inner glass wall of the vial — never directly onto the powder. This prevents peptide degradation.
4
Gently swirl (do not shake) until solution is completely clear. Allow 1–2 minutes to fully dissolve.
5
Refrigerate immediately at 2–8°C (36–46°F). Reconstituted peptides are stable 4–6 weeks refrigerated. Dry lyophilized vials can be frozen 12+ months.
Subcutaneous Injection Technique
1
Pinch the skin — use thumb and forefinger to lift a 1–2 inch fold. This ensures you're injecting into subcutaneous fat, not muscle.
2
Insert needle at 45° — for leaner individuals, 45° is standard. More body fat: 90° is also acceptable. Insert in one smooth, confident motion.
3
Release the pinch once the needle is fully inserted — let go of the skin fold before pushing the plunger.
4
Inject slowly — push the plunger steadily over 5–10 seconds. Fast injection increases discomfort and the chance of a bump.
5
Remove & hold — withdraw the needle and apply light pressure with a clean swab for 10 seconds. Do not rub — rubbing disperses the peptide unevenly.
6
Rotate injection sites every dose. Preferred sites in order: upper abdomen (left/right of navel), lower abdomen, outer thigh. Never inject the same spot twice in a row.