User Registration

Name*
First Name * Last Name *
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Communication
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- Opt In promotions
Email Address*

Note: a valid email address is required to complete registration!
Username
Password*
Enter Password Confirm Password
I am over 18 years old*
- YES
Birth Date*
Date Format: DD dash MM dash YYYY
Sex*
- Male
- Female
- Other
Please Specify Sex

CURRENT MEDICATIONS
Are you taking any prescribed medications?*
- No
- Yes
If yes, please list the medication name, dose and reason for use.*
Are you currently taking anything not prescribed by a Doctor? (i.e. supplements or vitamins)*
- No
- Yes
If yes, please list the medication name, dose and reason for use (if applicable).*
Have you ever taken Peptides in the past?*
- No
- Yes
If yes, please specify the name, potency, dose & when you took the cycle.*
Have you ever taken anabolic steroids or been prescribed hormone replacements in the past?*
- No
- Yes
If yes, please specify the name, potency, dose & when you took the cycle.*

MEDICAL CONSENT
Consent*
MEDICAL CONSENT

To finalise your registration and become a patient with Peptides Direct by RegenMed, you must read the statements below and agree using the check box provided.

Once you have successfully consented and submitted your registration form you will become a patient and receive confirmation via your nominated email address. Patients have full access to browse the full range of peptides, medication and supplements we supply, as well as place an order.

Please read these statements carefully and provide your consent.

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I acknowledge that a RegenMed Doctor will review my medical history and may prescribe the selected medication or peptide if they deem it appropriate and safe to do so. I understand that keeping my medical history up to date is essential to help the Medical Team determine which solutions may be most effective and appropriate for me.

I acknowledge that any non-prescription supplements, vitamins and minerals purchased from RegenMed are taken at my own risk and are not prescribed by a medical professional.

I agree that RegenMed reserves the right to refuse access to their service or supply of products to any individual based on any criteria they deem necessary.

I understand that if I do not follow the dosing and administration instructions from the prescribing doctor or pharmacy that I will be wholly responsible for any issues I experience.

I acknowledge that RegenMed reserves the right to refuse me as a patient if I do not follow the doctor's instructions. I agree that RegenMed reserves the right to refuse access to their service or supply of products to any individual based on any criteria they deem necessary.

I have provided the most truthful and up to date information in my medical history and registration form, and acknowledge that failing to do so or purposely providing fraudulent information gives RegenMed the right to refuse service as well as pursue legal action if necessary. If any information provided in my medical history or registration form changes I agree to notify the team as soon as possible, and will keep them informed of any changes to my medical history or medication.

I understand that Peptides are still classed as research medications and that the human data and medical research on these medications are limited.

I give the RegenMed Patient Care Team permission to contact me by phone or email for any reason relating to the service, including to update my Medical History, request pathology or further clarification and even to consult me about product selection.

I acknowledge that the Medical Team will send confirmation to my nominated email address once my product selection has been approved and scripted based on the medical history provided. I consent to being contacted by the Medical Team via phone or email if there any further information is required. If the Doctor refuses to prescribe my selected medication I consent to being contacted to find an alternative medication or issue a refund. I understand that a comprehensive consultation with my prescribing Doctor is available at an extra cost.

I agree to inform RegenMed of any adverse reactions to medications or supplements supplied by RegenMed as soon as possible.

I consent to my de-identified (statistical) medical data to be used for future medical research. I understand that this data does not contain my identifiable personal information.

I understand that RegenMed does not hold any compounded products or medication on hand and all medications & supplements are compounded as scripted by Australian only sterile compounding pharmacies. I understand that medications are sent from the pharmacy directly to the patient.
I agree to all statements above and the website terms and conditions.
Signature*

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Registration Form

Step 1 of 5 - Personal Information

INITIAL INSIGHTS

MEDICAL HISTORY

CURRENT MEDICATIONS

MEDICAL CONSENT