Known Treatment Request

Use this page if you already know what you want considered. List the items or treatment types, prior use, intended outcome and monthly budget.

What happens next: UHD builds the proposed protocol or order request, emails it to you for approval, then only proceeds to treatment payment and doctor review if you approve. Treatment is not guaranteed.

Name *

First

Last

Email *

Phone

Age

Confirm your request focus

Weight Management
Performance & Recovery
Recovery & Injury Support
Sleep & Stress
Healthy Ageing
Energy & Vitality

Have you previously used peptide therapy?

Do you currently know what you are interested in?

Yes
No
Not sure

If answered yes to above, please list

Do you currently have any diagnosed medical conditions?

years? had Have

Current Medications ( If any )

Have you had cancer diagnosed within the last 5 years?

Are you currently pregnant or breastfeeding?

Have you ever experienced serious reactions to medications or injections?

Have you got recent blood work?

Any additional info you want us to know?

Do you understand that all treatments are subject to doctor approval ?

This form is an application for portal access and treatment pathway review.

Once submitted, our team will MANUALLY assess your details and contact you via email regarding eligibility, next steps and potential approval for access.

Please ensure all information provided is accurate.

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