Patient Onboarding

Welcome, New Patient

Complete your registration securely in one sitting—your health history intake, purchase agreement, and peptide waiver are all here. It takes about 10 minutes.

Three Steps

What You'll Complete Today

All forms are submitted securely. Signed documents are saved to your patient profile and emailed to you upon completion.

01
Intake Form

Health History & Wellness Intake

Your medical background, current medications, allergies, lifestyle habits, and wellness goals. This information helps Jacqueline build your personalized treatment plan.

02
Sign & Acknowledge

Research Peptide Waiver

Acknowledges the research-only FDA status of peptide compounds, your voluntary and informed consent, and assumption of risk. Required before any product is dispensed.

03
Sign & Initial

Peptide Purchase Agreement

Covers your selected program, payment terms, no-refund policy, and limitation of liability. You will initial your program choice and sign at the bottom.

Before You Begin

What to Have on Hand

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Personal Information

Your full legal name, date of birth, phone number, email address, and emergency contact details.

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Current Medications & Supplements

A list of everything you currently take, including dosages if possible. This includes prescriptions, OTC medications, and supplements.

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Medical History

Any diagnosed conditions, past surgeries, known allergies, and relevant family history you'd like Jacqueline to be aware of.

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10 Minutes & a Quiet Moment

The full onboarding takes approximately 10 minutes. Complete it in one session—your progress may not be saved if you close the form early.

Secure Patient Portal

Complete Your Registration Below

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Your information is protected. This portal is powered by IntakeQ, a HIPAA-compliant patient intake platform. All data is encrypted in transit and at rest. Signed documents are delivered securely to both you and your provider.

01
Health Intake
02
Peptide Waiver
03
Purchase Agreement
01

Health History & Wellness Intake

Your medical background, medications, allergies, lifestyle habits, and wellness goals.

Patient Information
Medical History
High Blood Pressure
Heart Disease
Diabetes / Insulin Resistance
Thyroid Disorder
Cancer History
Autoimmune Disease
Anxiety / Depression
Sleep Apnea
Hormonal Imbalance
Other
Current Medications & Supplements
Allergies
Lifestyle & Wellness
Do you smoke or use nicotine products?
Do you drink alcohol regularly?
Do you exercise regularly?
Do you have trouble sleeping?
Have you previously used peptides or GLP-1 medications?
Patient Goals
Acknowledgment & Signature
I certify that the information provided in this health history form is accurate and complete to the best of my knowledge. I understand that withholding medical information may impact my treatment recommendations and wellness plan.
Sign with mouse or finger

Ready to continue? Review your entries above, then advance to your next document.

02

Research Peptide Acknowledgment & Waiver of Liability

Please read each section carefully, check the required acknowledgments, and sign below.

Patient Information
Agreement Terms

1. Notice of Research-Only Status

I acknowledge that the above-listed compound(s) are supplied for research and educational purposes only and are not approved by the U.S. Food and Drug Administration (FDA) for the diagnosis, treatment, or prevention of any disease or medical condition. These products have not undergone the safety, efficacy, or quality review typically required for approved human use.

2. Voluntary Use and Informed Consent

I understand that any use of these compounds is entirely voluntary and undertaken at my own risk. I have been advised that limited human data exists regarding potential benefits, side effects, contraindications, or long-term effects. I have had the opportunity to ask questions, review available literature, and discuss potential alternatives with a qualified healthcare provider before deciding to proceed.

3. Assumption of Risk

I fully assume all risks, known and unknown, associated with the purchase, possession, administration, or use of these research peptides, including but not limited to allergic reactions, unexpected physiological effects, or lack of results.

4. Release and Hold Harmless

In consideration for being allowed to purchase or receive these products, I hereby release, discharge, and hold harmless the Clinic, its clinicians, employees, affiliates, distributors, manufacturers, and suppliers from any and all claims, liabilities, damages, or expenses arising directly or indirectly from the purchase, use, or misuse of these compounds, whether such claims are known or unknown, anticipated or unanticipated.

5. No Medical Guarantee

I understand that no guarantee, warranty, or representation has been made regarding the outcome, efficacy, or safety of any product, and that these peptides are provided "AS IS."

6. No Refund Policy

I acknowledge and agree that all peptide and research compound purchases are final sale. Due to the nature of these products, no refunds, returns, exchanges, or credits will be issued once purchased, dispensed, or shipped, regardless of unused product, perceived lack of efficacy, or change of decision.

7. Governing Law

This agreement shall be governed by the laws of the State in which the Clinic operates. If any provision is found unenforceable, the remaining provisions shall remain in full force and effect.

Required Acknowledgments
Signature
Sign with mouse or finger

Ready to continue? Ensure all acknowledgments are checked and your signature is complete.

03

Peptide Purchase Agreement

Select your program, review all terms, and sign below to complete your registration.

Patient Information
Program Selection *
Agreement Terms

1. Program Acknowledgment

I understand that peptide programs are individualized wellness programs that may include nutritional guidance, peptide education, lifestyle recommendations, and follow-up consultations. Results may vary between individuals.

2. Research & Regulatory Status

I acknowledge that certain peptide compounds may be considered investigational or research-use compounds and may not be approved by the U.S. Food and Drug Administration (FDA) for the diagnosis, treatment, cure, or prevention of disease.

3. Medical Disclosure

I certify that I have disclosed all known medical conditions, medications, allergies, and relevant health history to my healthcare provider prior to participating in any peptide program.

4. Assumption of Risk

I voluntarily assume all risks associated with peptide use, including but not limited to injection reactions, allergic reactions, side effects, lack of efficacy, misuse, improper storage, or unforeseen complications.

5. Payment Terms

I understand that payment is due prior to the dispensing or shipment of peptide products unless otherwise agreed upon in writing by the Clinic.

6. No Refund / Replacement Policy

I acknowledge and agree that all peptide purchases and wellness programs are final sale. Due to the nature of compounded and peptide-related products, no refunds, returns, exchanges, credits, replacements, or cancellations will be issued once payment has been processed, products dispensed, or shipped, including but not limited to change of mind, personal decision, perceived lack of efficacy, unused product, accidental damage, dropped or broken vials, improper storage, lost or misplaced product, or patient handling errors.

7. Subscription / Renewal Terms

If enrolled in a recurring wellness or peptide optimization program, I understand that future shipments, consultations, or renewals may occur according to the selected program duration unless canceled in accordance with clinic policy.

8. Limitation of Liability

I release and hold harmless JLS Integrative Beauty & Wellness, its providers, contractors, affiliates, and suppliers from any liability, damages, or claims arising from participation in peptide programs or use of peptide products.

9. Governing Law

This agreement shall be governed by the laws of the state in which the Clinic operates.

Required Acknowledgments
Signature
Sign with mouse or finger

Almost done! Review all entries, then submit to complete your registration.

✓

Registration Complete

Thank you! All three forms have been received. Jacqueline will review your information and reach out within 1–2 business days to confirm your program and next steps.

Questions? Email Us

Questions Before You Begin?

If you have any issues with the registration forms or questions about what to expect, reach out directly.

Book a Free Consultation First