Prescription Questionnaire

Step 1 of 30

Have you filled out the required forms for these products before?*

No, I have never filled out a medical questionnaire for these products.

Yes, I recently completed the medical questionnaire for these products.

When did it happen?*

I filled out the form during this visit and was redirected away from checkout.

I filled out the required questionnaire on my last purchase of this specific product.

Did you complete the questionnaire for this specific product in the last 90 days?*

Yes

Great! Let’s get you back to checkout. Simply read the disclaimer below and click Next. Please fill out the basic information below so we can match your name with your complete details.

Great! We can use some of the information from your last online visit and gather any additional details during your brief telehealth appointment. Please complete the basic information below so we can match your name with your full records.

No Problem! Let's get your online visit underway. Please read disclaimer and hit NEXT.

Name*

First Last

Email*

Phone*

Date of Birth*

Disclaimer*

I have read the disclaimer and understand I need to complete or I have completed the online visit within the last 90 days to reserve these products.

When ordering medications from Regen Doctors that require a prescription; you are reserving the medication until the prescription is provided from our physician. In order to complete the process and receive any medication, you must first answer the qualifying medical questionnaire that appears upon completion of checkout.

With the price of your medication, a free consultation with one of our licensed medical providers is provided to ensure that the medication is right for you. If you meet the requirements, our providers will write your prescription and your order will be completed.

Patient Information * (ALL fields required)

Name:*

First Last

Date of Birth:*

Phone Number:*

Email:*

Gender assigned at birth*

Male

Female

Do you smoke?*

Yes

Do you use recreational drugs?*

Yes

Because you marked “yes” on the previous question, please list any recreational drugs that you take on a regular basis:*

Current height:*

Current height (feet):*

Feet

Current height (inch):*

Inches

Current weight:*

lbs

Most recent Blood pressure: *

Most recent Blood pressure:

Unsure of Last Reading

Systolic (top number)*

Systolic (top number)

Diastolic (bottom number)*

Diastolic (bottom number)

Have you ever been told your Kidneys are not working properly?*

Yes

Have you ever been told your liver is not working properly?*

Yes

Have you had a general health check-up in the past 3 years?*

Yes

Have you had bloodwork drawn recently?*

Yes

Because you marked yes on the previous question, please choose which best applies to you: I have had my recent bloodwork taken:*

3-6 months ago

6-12 months ago

Over a year ago

I can't remember

This field is hidden when viewing the form

Are you taking any medications, including any over the counter?*

Yes

Because you marked “yes” on the previous question, please list any current medication (both prescription & over the counter) that you take on a regular basis*

Just a few more questions for you...

Medical Conditions:

Do you have or have you had any of the following medical conditions? (Check all that apply)*

High blood pressure

High cholesterol

Heart disease

Stroke or blood clots

Diabetes or prediabetes

Thyroid disorder

Hepatitis B or C

Thyroid disorder

HIV/AIDS

Kidney disease

Liver disease

Autoimmune disorder

Depression or anxiety

Asthma or COPD

Sleep apnea

Seizures

HIV/AIDS

None of the above

Other - my condition is not listed

Because you marked “Other” on the previous question, please list any additional medical conditions that you currently have or have had in the past:*

Surgical History:

Have you had any of the following surgeries? (Check all that apply)*

Back or Neck surgery

Hysterectomy (Female only)

Appendix

Heart surgery

Stenting prostate surgery (Men only)

Gallbladder

None of the above

Other- my surgery is not listed

Because you marked “Other”, please list any additional surgeries you have had or plan on having:*

Allergies (Check all that apply)*

Penicillin/Amoxicillin

Aspirin

Latex

Sulfa drugs

Codeine

Other

None of the above

Other:

Please select the products that you are purchasing today.

Sexual Wellness

PT-141 (any variation)

Sermorelin (Sexual wellness)

Tadalafil Sexual Melts

Tadalafil Oral Pills (Cialis®)

Sildenafil (Viagra®)

Sexual Wellness

PT-141 (any variation)

Sermorelin (Sexual wellness)

Tadalafil Sexual Melts

Weight Loss

Sermorelin (Weight Loss)

Semaglutide

Phentermine

Phendemetrazine

B12 Injections

Thermo Suppress

Anti-aging / Energy / Mental Health

NAD+

Sermorelin (Anti-Aging)

NMN300

Joint / Muscle Repair

Pentosan Polysulfate

Hormone Therapy

Gonadorelin

Testosterone

Hormone Therapy

Gonadorelin

Hair Loss

Nutrafol

Oral Finastride

Oral Minoxidil

GHK Zn-Thymulin

This field is hidden when viewing the form

Male

Sexual Wellness

Why are you interested in Regen Doctors’ Sexual Wellness products (Check all that apply)*

Difficulty forming an erection

Lasting longer/Performance Enhancement

Increase Sex Drive

Premature Ejaculation

Improve intimacy with partner

Have you ever been prescribed or used Nitrates? Examples include: Nitroglycerin (Nitro-Dur, Nitrolingual or Nitrostat), Isosorbide (Dilatrate or Isordil, Nitroprusside (Nitropress) or Amyl Nitrate (“Poppers”)*

Yes

Have you ever experienced any of the following? (check all that apply)*

Have had a bent/deformed penis shape or Peyronie’s disease

Have blood cell problems such as sickle cell anemia, multiple myeloma or leukemia

Have had an erection that lasted more than 4 hours

Trauma to the pelvic area

None of the above

Weight Loss

Why are you interested in this Weight loss product? (check all that apply)*

Lower blood sugar

Relieve PCOS/Menstrual symptoms

Regulate appetite

Encourage weight loss

Diabetes prevention/control

Reduce cravings

Increase energy

Other

Do you suffer from any of the following? (check all that apply)*

Endocrine Neoplasia II

High Blood pressure

Constipation

Pancreatitis

Anxiety

Insomnia

Medullary Thyroid Cancer

None of the above

Are you currently taking any other weight loss supplements?*

Yes

Because you marked “Yes” on the previous question, please list any weight loss supplements you are currently taking:*

Anti-aging/Energy/Mental Health

Why are you interested in this Anti-Aging Product? (Check all that apply)*

Faster Recovery

Improve Mood

Reverse/Slow Down the Aging Process

Longevity Benefits

Increase Energy

Improve Sleep

Increase Physical Endurance

Improve Cognitive Function

Joint/Muscle Repair

Do you have a history of blood disorders (low platelets, anemia, bleeding disorders)?*

Yes

Unsure

Have you ever had a blood clot, stroke, or deep vein thrombosis (DVT)?*

Yes

Are you currently taking any blood thinners (e.g., warfarin, apixaban, rivaroxaban, heparin)?*

Yes

Are you taking antiplatelet medications (e.g., aspirin, clopidogrel)?*

Yes

Hormone Therapy

Are you willing to undergo regular blood work (hormones, PSA, liver function, cholesterol, etc.)?*

Yes

Do you understand that testosterone and gonadorelin therapy require ongoing monitoring and medical supervision?*

Yes

Hair Loss

Why are you interested in Hair Loss Products?*

Regrow Hair

Address Overall Thinning Hair

Address Receding Hairline

Proactively Prevent Balding

What do you think is causing your hair loss?*

Male Pattern Baldness

Genetics

Stress

General aging/age related causes

Not sure

Do you have any open wounds or cuts on your scalp?*

Yes

This field is hidden when viewing the form

Female

Sexual Wellness

Why are you interested in Regen Doctors’ Sexual Wellness products (Check all that apply)*

Improve Intimacy With Partner

Achieve Orgasm Easier

Vaginal Dryness

Increase Sex Drive (Libido)

Other

Weight Loss

Do you suffer from any of the following? (check all that apply)*

Lower blood sugar

Relieve PCOS/Menstrual symptoms

Regulate appetite

Encourage weight loss

Diabetes prevention/control

Reduce cravings

Increase energy

Other

Why are you interested in Regen Doctors’ Sexual Wellness products (Check all that apply)*

Endocrine Neoplasia II

High Blood pressure

Constipation

Pancreatitis

Anxiety

Insomnia

Medullary Thyroid Cancer

None of the above

Are you currently taking any other weight loss supplements?*

Yes

Because you marked “Yes” on the previous question, please list any weight loss supplements you are currently taking:*

Anti-aging/Energy/Mental Health

Why are you interested in this Anti-Aging Product? (Check all that apply)*

Faster Recovery

Improve Mood

Reverse/Slow Down the Aging Process

Longevity Benefits

Increase Energy

Improve Sleep

Increase Physical Endurance

Improve Cognitive Function

Joint/Muscle Repair

Do you have a history of blood disorders (low platelets, anemia, bleeding disorders)?*

Yes

Unsure

Have you ever had a blood clot, stroke, or deep vein thrombosis (DVT)?*

Yes

Are you currently taking any blood thinners (e.g., warfarin, apixaban, rivaroxaban, heparin)?*

Yes

Are you taking antiplatelet medications (e.g., aspirin, clopidogrel)?*

Yes

Hormone Therapy

Are you willing to undergo regular blood work (hormones, liver function, cholesterol, etc.)?*

Yes

Do you understand that gonadorelin therapy requires ongoing monitoring and medical supervision?*

Yes

Have you experienced infertility or difficulty conceiving in the past?*

Yes

Unsure

Hair Loss

Why are you interested in Hair Loss Products?*

Regrow Hair

Address Overall Thinning Hair

Address Receding Hairline

Proactively Prevent Balding

What do you think is causing your hair loss?*

Genetics

Stress

General aging/age related causes

Not sure

Do you have any open wounds or cuts on your scalp?*

Yes

Semaglutide Consent

By choosing to begin Semaglutide therapy, I acknowledge and agree to the following:

I understand that Semaglutide is a prescription medication used for weight management and/or blood sugar control.
I have disclosed my complete medical history, including any history of pancreatitis, gallbladder disease, thyroid cancer, or multiple endocrine neoplasia (MEN2).
I understand that possible side effects may include nausea, vomiting, diarrhea, abdominal pain, constipation, and rarely, more serious complications such as pancreatitis or thyroid tumors.
I understand that Semaglutide is not approved for use during pregnancy or breastfeeding.
· I agree to follow the prescribed dosing schedule and attend recommended follow-up appointments and lab testing.
I acknowledge that results vary and weight loss or other benefits are not guaranteed.
I understand this is a medical treatment that requires monitoring and should only be used under the supervision of a licensed provider.

Consent*

By proceeding, I give my informed consent to begin Semaglutide therapy.

Testosterone Therapy Consent

By choosing to begin Testosterone therapy, I acknowledge and agree to the following:

I understand that Testosterone is a prescription medication used for the treatment of low hormone levels and related symptoms.
I have provided my complete medical history, including any history of prostate cancer, breast cancer, heart disease, stroke, blood clots, liver disease, or sleep apnea.
I understand that possible side effects may include acne, hair loss, mood changes, breast tenderness, increased red blood cell count, prostate changes, and changes in fertility.
I understand Testosterone therapy may reduce sperm production and affect future fertility.
I understand that Testosterone therapy requires ongoing monitoring, including lab work and follow-up visits.
I acknowledge that results vary and symptom improvement is not guaranteed.
I understand this treatment must be prescribed and monitored by a licensed medical provider.

Consent*

By proceeding, I give my informed consent to begin Testosterone therapy

Telehealth Consent

By participating in a telehealth visit, I understand and agree to the following:

Telehealth involves the use of electronic communications to enable healthcare services when I am not in the same location as my provider.
I understand the benefits (such as convenience and accessibility) and potential risks (including technical failures, limited physical examination, and privacy concerns).
My medical information will be protected under HIPAA and applicable privacy laws, but electronic communication may still carry some risks.
I have the right to stop or refuse telehealth services at any time without affecting my right to future care.
I understand that my provider may determine telehealth is not appropriate for my condition and recommend in-person care.
I consent to receive care and treatment via telehealth.

Signature*

Date*

GENERAL Signature & Consent

I certify that the above information is accurate to the best of my knowledge. I consent to treatment recommendations based on this information.

Signature*

Date*

Click submit to proceed to checkout.

General Intake Questions

Great! Let’s get you back to checkout. Simply read the disclaimer below and click Next. Please fill out the basic information below so we can match your name with your complete details.

Great! We can use some of the information from your last online visit and gather any additional details during your brief telehealth appointment. Please complete the basic information below so we can match your name with your full records.

No Problem! Let's get your online visit underway. Please read disclaimer and hit NEXT.

Patient Information * (ALL fields required)

Medical Conditions:

Surgical History:

Please select the products that you are purchasing today.

Sexual Wellness

Weight Loss

Anti-aging / Energy / Mental Health

Joint / Muscle Repair

Hormone Therapy

Hair Loss

Male

Sexual Wellness

Weight Loss

Anti-aging/Energy/Mental Health

Joint/Muscle Repair

Hormone Therapy

Hair Loss

Female

Sexual Wellness

Weight Loss

Anti-aging/Energy/Mental Health

Joint/Muscle Repair

Hormone Therapy

Hair Loss

Social

Popular

Quick Links

Legal

Cookie Privacy

© 2026 REGEN DOCTORS - All Rights Reserved