Growth-Hormone Peptide — Health Questionnaire

About you

We need this to ship your medication and verify your identity.

First name Last name Email Phone Date of birth Biological sex

Shipping address

Street address Apt / Suite (optional) City State ZIP

General health history

Basic background the physician needs to review.

Height (feet) Height (inches) Current weight (lbs) Target weight (lbs)

Current medications (include dose if known — separate with commas) Drug or food allergies Major medical conditions (current or past)

Tesamorelin candidacy screening

A few targeted questions so the physician can write the right script safely.

Do you have active cancer, or a history of cancer in the last 5 years?

⚠ Growth-hormone axis stimulation warrants caution with active or recent malignancy.

No Yes

Do you have a pituitary tumor, hypopituitarism, or a history of head/pituitary radiation or surgery?

⚠ Tesamorelin works by stimulating your pituitary to release growth hormone, so pituitary history is directly relevant.

No Yes

Do you have diabetes with retinopathy, or currently uncontrolled blood sugar? No Yes

Do you have a known allergy to tesamorelin or mannitol?

⚠ Physician will review carefully.

No Yes

Are you currently taking growth hormone or other GH secretagogues (other GH peptides, GH injections)? No Yes

Anything else the physician should know? (optional)

Confirm your tesamorelin program

Tesamorelin bundles the consult, the medication, and ongoing follow-ups as needed. Your physician confirms candidacy during review.

Peptide Option

Tesamorelin

FDA-approved GH-releasing peptide. Most extensively studied for visceral and truncal fat reduction.

Pricing confirmed by your physician after review

Save your payment method

⚡ Your card will not be charged today. It is saved securely with Stripe and will only be charged once a physician reviews your case and approves your script. If you are not approved, no charge is made.

By continuing you authorize My4MLife and our network physicians to use this saved payment method to charge your selected monthly subscription if and when a script is written for you. You can cancel anytime by emailing support@my4mlife.com.

Review and submit

Confirm everything looks right. After submission, our care coordinator will email you within 24 hours to confirm next steps with the network physician.

I attest the information above is accurate to the best of my knowledge. I understand a real physician will review my submission, and that no medication will ship without a written script. I authorize My4MLife and the network physician to contact me by email or phone. I acknowledge I have received and reviewed My4MLife's Notice of Privacy Practices. I authorize My4MLife and its network physicians to use and disclose my health information to provide, coordinate, and bill for my care, including forwarding my intake to the telemedicine provider, as described in the Patient Authorization & Telehealth Consent.

✓

Your submission is in.

Our care coordinator will email you within 24 hours to confirm the next step with the network physician. Your card has been saved securely with Stripe — no charge has been made and none will be made until your script is approved.

Questions? Email support@my4mlife.com.

Search

Let's get you matched with a physician

About you

Shipping address

General health history

Tesamorelin candidacy screening

Confirm your tesamorelin program

Tesamorelin

Save your payment method

Review and submit

Your submission is in.