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If you're familiar with peptides, please click up to five that you're interested in exploring. (Below are their names and potential benefits to help guide your selection.)
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Select up to five peptides.
Have you used peptides before? If yes, please list the ones you’ve tried and share your experience with them (what you liked, didn’t like, or any noticeable effects).
Are you only interested in NAD+? If so, bloodwork is not required. However, if you're considering other peptides in addition to NAD+, we will need you to submit your bloodwork to move forward with a personalized plan.
Do you have any pre-existing medical conditions?
Do you have a history of cancer? If yes, please provide details (type of cancer, year diagnosed, year in remission, etc)
Do you have a family history of cancer? If yes please provide type of cancer and relationship
Please list the supplements you are currently taking.
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Please list the medications you are currently taking.
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Please list any allergies or sensitivities to food, supplements, animals or chemicals.
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Have you had any recent hospitalizations? If so, please explain.
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How many hours of sleep do you typically get per night?
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Do you consume alcohol?
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Do you use tobacco or nicotine products?
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What is your current activity level
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On a scale of 1 to 10 (1 = No Stress, 10 = Extremely High Stress), how would you rate your current stress level?
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Do you have any weight concerns? If so, how much weight would you like to lose or gain?
Do you follow a specific diet or nutrition plan? If yes, please describe.
Do you have any food preferences or restrictions (gluten free or vegetarian for example).
Do you consent to a Peptide Consultant reviewing this information to create a personalized wellness plan?
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Are you interested in working with a Coach/Educator on a monthly basis?
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Do you have current and up-to-date bloodwork?
Anything else you'd like to share!
Acknowledgment & Release of Liability. By submitting this intake form, I acknowledge and agree to the following: 1. Wellness Services Disclaimer: • I understand that Loop Health & Wellness is not a medical provider and does not diagnose, treat, or prescribe medications. • All services provided by Loop Health & Wellness are for informational and educational purposes only and do not replace medical advice from a licensed healthcare provider. • I understand that any insights generated by AI are for informational purposes only and do not constitute medical advice, diagnosis, or treatment. These insights are not intended to replace consultation with a licensed healthcare provider. 2. Personal Responsibility & Consultation with a Medical Professional: • I take full responsibility for my health decisions and understand that any recommendations made by Loop Health & Wellness are not medical advice. • I agree to consult a licensed healthcare provider regarding any medical concerns or before starting any wellness, supplement, or peptide protocol. • If I have not seen my primary care provider (PCP) within the past six months, I understand that it is advised that I schedule an appointment with my PCP within the next 30 days. 3. Peptide Use & Assumption of Risk: • I understand that peptides are for research purposes only and have not been evaluated or approved by the FDA for human consumption. • I assume all risks associated with the purchase and use of peptides and acknowledge that Loop Health & Wellness makes no claims regarding their safety, efficacy, or intended use. • I agree that Loop Health & Wellness is not liable for any effects, side effects, or consequences resulting from the use of peptides. 4. Blood Work & Monitoring Responsibility: • I understand that it is my responsibility to review my blood work or order updated lab work every six weeks with my physician. • I acknowledge that Loop Health & Wellness does not interpret blood work for medical purposes and any insights provided are for general wellness education only. • I authorize Loop Health & Wellness to process my submitted blood work using AI-driven technology to generate research-based wellness insights. I understand that AI-generated reports are based on publicly available research and data trends, not medical evaluations. 5. Release of Liability: • I hereby release, waive, and discharge Loop Health & Wellness, its owners, employees, and affiliates from any and all claims, liabilities, damages, or losses arising from my participation in any wellness program, the use of peptides, or reliance on any educational content provided. • I understand that I voluntarily assume all risks related to my participation in Loop Health & Wellness programs and services. • I acknowledge that Loop Health, its Coaches, and Educators are not liable for any health concerns, medical issues, or any other related matters once I start the program. I assume full responsibility for my health and wellness decisions. • I release Loop Health & Wellness from any liability related to AI-generated insights, including but not limited to misinterpretation of data, incorrect assumptions, or personal decisions made based on AI-reviewed blood work. I assume full responsibility for how I use this information. By submitting this form, I confirm that I have read, understand, and agree to the terms outlined in this Consent & Liability Waiver.
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Thank You for Submitting Your Inquiry! We’re so excited you’ve taken this first step in your peptide journey with LOOP. Your intake form has been received, and our team is reviewing it carefully to ensure you get the best support and experience possible.
You’ll hear from us soon with your next steps.
We’ll guide you through the process, help you understand what to expect, and make sure you feel confident as you move forward.
In the meantime, be sure to add support@theloopway.com to your contacts so our emails don’t end up in your spam folder.
We can’t wait to support you on this journey!— Steph
