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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 benefits or goals best describe why you’re taking this protocol?
Select up to 3 options that best match your goals.
Selected: 0/3
Tendon, ligament, or connective tissue repair
Joint health and mobility
Recovery from training, injury, or surgery
Gut barrier and digestive health
Inflammation reduction and immune balance
Autoimmune condition support
Collagen synthesis and skin repair
Cognitive resilience and stress tolerance
Overall tissue regeneration and structural repair
Do any of the following apply to you?
Selected: 0/1
None
Severe allergic reaction to injectable medications or peptides
Wilson's disease or any copper metabolism disorder or known copper overload
Are you currently taking immunosuppressants, biologics, or chronic corticosteroids?
No
Yes
Do any of the following apply to you?
Selected: 0/1
None
Bleeding disorder or take blood thinners (e.g., warfarin, Eliquis, Xarelto, Plavix, high-dose aspirin)
Have an open wound, a fracture, or a recent injury that has not yet been medically evaluated or stabilized
Have surgery scheduled within the next 30 days or are you within 15 days post-surgery
Do any of the following apply to you?
Selected: 0/1
None
Have poorly controlled diabetes, neuropathy, or circulation issues
You are a competitive athlete subject to drug testing (e.g., WADA or similar organizations)
Do any of the following apply to you?
Selected: 0/1
None
Currently have a significant active infection (e.g., fever, systemic illness, or requiring antibiotics)
You Have significant liver disease or cirrhosis
You Had a prior sensitivity or reaction to copper-containing products
Are you willing to accept potential side effects of this therapy and inform your other healthcare providers that you are taking it?
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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