Become a patient – PeptiClinic

👤Personal Information

Let's start with your basic details.

First Name *

Please enter your first name

Last Name *

Please enter your last name

Date of Birth *

Please enter your date of birth

Gender at Birth *

Please select your gender

Email Address *

Please enter a valid email

Mobile Number *

Please enter your mobile number

Street Address *

Please enter your address

Suburb *

Required

State *

Required

Postcode *

Required

🆔 Medicare Details (optional)

Medicare Number

Reference (IRN)

🏥 Emergency Contact

Contact Name *

Required

Contact Phone *

Required

🏥Medical History

This information helps our practitioners provide safe, personalised care.

ℹ️

All information is kept strictly confidential and protected under Australian Privacy Principles.

Current Medications (if any)

Include prescription, over-the-counter, and supplements

Known Allergies (if any)

Do you have any of the following conditions?

Diabetes

High blood pressure

Heart disease

Thyroid disorder

Kidney disease

Liver disease

None of the above

Previous Surgeries (if any)

Family Medical History (relevant conditions)

🏃Lifestyle

Understanding your lifestyle helps us create a personalised treatment plan.

Height *

Please enter your height

Weight *

Please enter your weight

How would you describe your activity level? *

Sedentary

Little to no regular exercise

Lightly Active

Light exercise 1-3 days/week

Moderately Active

Exercise 3-5 days/week

Very Active

Hard exercise 6-7 days/week

Do you smoke?

Never

Former

Current

Alcohol consumption

None

Occasional

Moderate

Heavy

How would you rate your sleep quality?

Poor

Fair

Good

Excellent

🎯Your Goals

Tell us what you're hoping to achieve.

What services are you interested in? *

Weight Management

Fat loss, metabolism support

Muscle Building

Strength, lean mass

Anti-Ageing

Skin, vitality, longevity

Injury & Recovery

Healing, tissue repair

Sexual Performance

Libido, function

Hormone Therapy

TRT, HRT, optimisation

Mood & Cognitive

Focus, clarity, wellbeing

Sleep & Restoration

Better rest, recovery

Please select at least one service

What are your main health goals?

Have you used peptides or similar treatments before?

No, I'm new

Some experience

Experienced

How did you hear about us?

📋Consents & Agreements

Please review and accept the following to complete your registration.

Telehealth Consent *

I understand that consultations will be conducted via telehealth (video call) and consent to receiving healthcare services in this manner.

Privacy Policy *

I have read and agree to the Privacy Policy and understand how my personal and health information will be collected, used, and stored.

Terms of Service *

I have read and agree to the Terms of Service including the cancellation and refund policy.

Accurate Information *

I confirm that all information provided in this form is accurate and complete to the best of my knowledge.

Marketing Communications (optional)

I would like to receive updates about new services, promotions, and health tips via email.

⚠️

Important: Peptide therapy is not suitable for everyone. Final eligibility will be determined by your practitioner during your consultation.

Patient Onboarding

Got questions? Call us on:

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Services

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