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Product Intake Form
Personalized Protocol for Product Name
Complete this brief assessment to ensure your treatment is safe, effective, and tailored to your goals.
Which 3 benefits matter most to you right now with GHK-Cu?
Select up to 3 options that best match your goals.
Selected: 0/3
Reduce wrinkles & fine lines
Firm & tighten skin
Brighten uneven tone
Heal & repair faster
Calm redness & irritation
Protect against damage
Boost overall glow
Do any of the following apply to you?
Selected: 0/1
None
Known allergy to copper or copper peptides
Wilson's disease or any copper metabolism disorder
Do you have open wounds, severe acne, active skin infection, or have had a skin procedure (peel, microneedling, laser) in the last two weeks?
No
Yes
Do you have very sensitive skin (eczema, rosacea, dermatitis, frequent irritation)?
No
Yes
Are you currently using strong actives on your face (like prescription retinoids, high-strength acids, or benzoyl peroxide)?
No
Yes
Do you agree to inform your other healthcare providers that you are starting NAD⁺ therapy and continue regular check-ups with them?
Yes
No, decline treatment
Do you agree to inform your other healthcare providers that you are starting NAD⁺ therapy and continue regular check-ups with them?
Yes
No, decline treatment
Safety Check
Please review the following.
YOU'RE ALMOST DONE
You're one step away from completing your intake form but we still need your other products medical intake forms.
What happens next:
- Your responses will be securely stored
- You'll be redirected to complete additional product forms
Final Step
COMPLETE SUBMISSION
Thank you for completing your medical intake form, to finish the process please click the submit button.
Your submission is secure and encrypted
- Your provider will review your medical information within 24 hours
- You'll receive an email confirmation shortly
- Questions? Contact support anytime
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