| Peptides

Your Details

LET'S START WITH
YOUR DETAILS

We'll use this to send your results and book your consultation.

First Name *

Last Name *

Email *

Phone *

What type of work do you do? (optional)

Age Range *

Height (cm) (optional)

Weight (kg) (optional)

Primary Goal

WHAT'S YOUR
PRIMARY GOAL?

Select the one that matters most to you right now.

Testosterone — 1 of 3

WHICH SYMPTOMS ARE YOU
EXPERIENCING?

Select all that apply to you.

Testosterone — 2 of 3

HOW LONG HAVE YOU
BEEN EXPERIENCING THIS?

Testosterone — 3 of 3

WHAT'S YOUR MAIN
GOAL RIGHT NOW?

Weight Loss — 1 of 2

HOW MUCH WEIGHT
DO YOU WANT TO LOSE?

Weight Loss — 2 of 2

WHAT HAVE YOU
TRIED SO FAR?

Select all that apply.

Any of the following apply?

Performance — 1 of 3

WHAT WOULD YOU
LIKE TO IMPROVE?

Select all that apply.

What's your training like right now?

Performance — 2 of 3

WHAT'S HOLDING
YOU BACK?

Select all that apply.

Are you open to hormone or supplement-based support?

Performance — 3 of 3

WHAT'S YOUR TOP
PRIORITY RIGHT NOW?

Recovery — 1 of 3

WHAT TYPE OF INJURY
ARE YOU DEALING WITH?

Recovery — 2 of 3

TELL US MORE ABOUT
YOUR INJURY

How long has this been bothering you?

Pain level today (0–10)

0 10 5

Have you tried anything so far? (select all)

Recovery — 3 of 3

WHAT'S YOUR
RECOVERY GOAL?

Assessment — 1 of 3

WHAT ARE YOU
EXPERIENCING?

Select all that apply.

Assessment — 2 of 3

WHAT HAVE YOU
TRIED SO FAR?

Select all that apply.

How long has this been going on?

Assessment — 3 of 3

WHAT DO YOU WANT
TO ACHIEVE?

Select all that apply.

Medical — 1 of 5

CURRENT
MEDICATIONS

Please be honest — this helps our doctors prescribe safely.

Current prescription medications *

Any supplements, hormones, or peptides?

Medical — 2 of 5

MEDICAL
CONDITIONS

Liver conditions?

Kidney disease?

Cardiovascular disease? (select all)

Mental health conditions? (select all)

Sleep apnoea?

Medical — 3 of 5

LIFESTYLE

Do you smoke?

Recreational drug use? (select all)

Do you consume alcohol?

How many standard drinks per week? (if applicable)

Medical — 4 of 5

ACTIVITY &
EXERCISE

What's your activity level at work?

How often do you exercise?

What type of exercise? (select all)

Medical — 5 of 5

SLEEP &
RECOVERY

How many hours of sleep per night?

Any sleep difficulties? (select all)

TRT Screening — 1 of 4

BLOOD TEST
HISTORY

Have you had blood tests in the past 12 weeks?

Were they taken before 10am?

Were they taken fasting?

Have you had two separate low testosterone results?

Upload your blood test results (optional, PDF or image, max 10MB) Click to upload or drag and drop

TRT Screening — 2 of 4

TRT
CONTRAINDICATIONS

Have you ever been diagnosed with any of the following?

TRT Screening — 3 of 4

CURRENT TRT
STATUS

Are you currently on TRT?

Upload pre-TRT blood results (optional) Click to upload or drag and drop

TRT Screening — 4 of 4

FERTILITY
CONSIDERATIONS

Are you planning to conceive in the next 12–18 months?

Do you understand that testosterone can suppress fertility?

Nutrition

NUTRITION &
DIET

Do you track calories or macros?

What best describes your diet? (select all)

Almost Done

WRAP UP

How often would you like support/check-ins?

Anything else the clinical team should know? (optional)

I consent to my consultation being recorded for quality assurance and clinical compliance purposes.

Consent

REVIEW & SIGN
CONSENT

Terms & Conditions

Telehealth Consultation

By proceeding, you consent to a telehealth consultation with a Primal Zone medical practitioner. This consultation may include discussion of your health history, symptoms, and treatment options.

Privacy & Data

Your personal and medical information will be stored securely in accordance with the Australian Privacy Principles and used solely for the purpose of providing medical care.

Treatment Acknowledgement

You acknowledge that any treatment prescribed is based on your honest disclosure of medical history. Withholding information may affect the safety of your treatment.

Cancellation Policy

Consultations cancelled with less than 24 hours notice may incur a cancellation fee.

I have read and agree to the Terms & Conditions above.

Electronic Signature — Full Name *

Identity Verification

VERIFY YOUR
IDENTITY

Required for prescription medications under Australian law.

Medicare Number

Reference Number

Medicare Expiry

Upload Photo ID (Driver's licence or passport, max 10MB) Click to upload or drag and drop

THANK YOU!

Your assessment has been submitted. Our team will review your details and be in touch shortly to book your consultation.

Assessment Complete

Your information has been securely submitted

2

Doctor Review

A doctor will review your assessment within 24 hours

3

Book Consultation

We'll contact you to schedule your consultation

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YOUR BEST UNLEASHED.

LET'S START WITH
YOUR DETAILS

WHAT'S YOUR
PRIMARY GOAL?

WHICH SYMPTOMS ARE YOU
EXPERIENCING?

HOW LONG HAVE YOU
BEEN EXPERIENCING THIS?

WHAT'S YOUR MAIN
GOAL RIGHT NOW?

HOW MUCH WEIGHT
DO YOU WANT TO LOSE?

WHAT HAVE YOU
TRIED SO FAR?

WHAT WOULD YOU
LIKE TO IMPROVE?

WHAT'S HOLDING
YOU BACK?

WHAT'S YOUR TOP
PRIORITY RIGHT NOW?

WHAT TYPE OF INJURY
ARE YOU DEALING WITH?

TELL US MORE ABOUT
YOUR INJURY

WHAT'S YOUR
RECOVERY GOAL?

WHAT ARE YOU
EXPERIENCING?

WHAT HAVE YOU
TRIED SO FAR?

WHAT DO YOU WANT
TO ACHIEVE?

CURRENT
MEDICATIONS

MEDICAL
CONDITIONS

LIFESTYLE

ACTIVITY &
EXERCISE

SLEEP &
RECOVERY

BLOOD TEST
HISTORY

TRT
CONTRAINDICATIONS

CURRENT TRT
STATUS

FERTILITY
CONSIDERATIONS

NUTRITION &
DIET

WRAP UP

VERIFY YOUR
IDENTITY

THANK YOU!