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Let’s start with your personal information

Gender

Full Legal Name

First Last

Date of Birth

MM slash DD slash YYYY

Nationality / Country of Residence

Emirates ID / Passport Number

Contact Phone

Password

Enter Password Confirm Password

Address

Street Address Address Line 2 City State / Province / Region

Preferred Language

If other, please provide details.

Emergency Contact

Emergency Contact (Name)

Emergency Contact (Relationship)

Emergency Contact (Phone)

Have you used a telehealth service in Dubai before?

Yes

Consent to telehealth:

I understand the nature, benefits, and limitations of telehealth consultations.
I consent to the use of secure digital platforms, encryption, data storage, and transfer of my health records.
I understand I may request in-person referral if needed.
I agree that we may collect medical data, lab reports, wearable data, and store that information in compliance with UAE ICT / DHA telehealth data privacy standards.
I understand the risk of technology failure and that alternative contact methods are available.

General Health &
Medical History

Height (cm)

Weight (kg)

BMI (if known)

Do you smoke tobacco or use vaping / nicotine products?

Yes

Do you consume alcohol or recreational substances?

Yes

Do you use caffeine / energy drinks / stimulants?

Yes

Current medications / supplements / herbs (dose, frequency)

Allergies (medications, food, environmental)

Past serious illnesses, hospitalisations, surgeries (with dates)

Do you have any of the following chronic conditions? (check all that apply)

Hypertension / Heart Disease / Angina

Stroke / Cerebrovascular Disease

Diabetes / Insulin Resistance

Dyslipidaemia (high cholesterol / triglycerides)

Kidney Disease / Reduced Kidney Function

Liver Disease / Hepatitis

Thyroid disease (hypothyroid / hyperthyroid)

Autoimmune Disease

Cancer or History of Malignancy

Respiratory Disease / Asthma / COPD

Sleep Apnea

Gastrointestinal Disease (IBD, ulcers, etc.)

Neurologic / Seizure Disorder

Psychiatric / Mood / Anxiety / Depression

Osteoporosis / Bone disease

Blood Disorders / Clotting Disorder

Infectious Diseases (HIV, hepatitis B / C, etc.)

Are there any medications you are unable to take (due to side effects, intolerance, contraindications)?

Yes

If yes, please provide details.

Family history (parents, siblings):

Cardiovascular disease (heart attacks, strokes)

Diabetes

Cancer

Neurodegenerative disease (Alzheimer’s, Parkinson’s)

Autoimmune disease

Do you have any implants, devices, or prosthetics (e.g. pacemaker, metal implants, stents)?

Yes

If yes, please provide details.

Do you have any bleeding disorders or are you on anticoagulants / blood thinners?

Yes

If yes, please provide details.

Any recent major events (past 6 months): hospital admissions, accidents, fractures, new diagnoses?

Yes

If yes, please provide details.

Any recent major events (past 6 months):Do you travel frequently across time zones (jet lag, circadian disruption)?

Yes

If yes, please provide details.

Cardiovascular &
Metabolic Screening

Resting blood pressure (if known)

Resting heart rate (bpm)

Do you experience chest pain, palpitations, or unexplained shortness of breath?

Yes

Do you have peripheral edema (swelling in ankles, feet)?

Yes

Have you had any abnormal ECG / stress tests / echocardiogram results?

Yes

Have you been diagnosed with coronary artery disease, heart failure, or arrhythmia?

Yes

Do you know your most recent fasting glucose / HbA1c?

Yes

Do you have insulin resistance or metabolic syndrome?

Yes

Do you have elevated cholesterol or triglycerides?

Yes

Do you have any history of lipid-lowering medications (statins, fibrates)?

Yes

Any history of pancreatitis, gallstones, or fatty liver disease?

Yes

Do you experience episodes of hypoglycemia (low blood sugar)?

Yes

Hormonal, Reproductive
& Sexual Health

For All Patients

Do you have issues with libido, fatigue, mood fluctuation?

Yes

Have you ever been diagnosed with endocrine disorders (e.g. pituitary, adrenal, hypothalamic)?

Yes

Do you use hormone therapies currently (thyroid, estrogen, testosterone, DHEA, etc.)?

Yes

Have you had hormonal lab tests before (testosterone, estradiol, LH, FSH, cortisol, IGF-1, etc.)?

Yes

Additional for Females

Menstrual history

Age of Menarche

Regularity

Cycle Length

Last Menstrual Period

Menopausal Status

Any history of PCOS, endometriosis, uterine fibroids, heavy / painful menses

Yes

Are you pregnant, planning pregnancy, or breastfeeding?

Pregnant

Planning Pregnancy

Breastfeeding

Do you use hormonal contraception or hormone replacement therapy?

Hormonal Contraception

Hormone Replacement Therapy

None

Any history of miscarriages, infertility, or assisted reproduction?

Yes

History of breast disease, cervical disease / HPV, ovarian disease

Yes

Do you experience perimenopausal symptoms (hot flashes, mood swings, night sweats)?

Yes

Additional for Males

Do you have erectile dysfunction, low libido, or fertility issues?

Yes

Have you ever had testicular disease, varicocele, prostate enlargement / PSA testing?

Yes

Do you take testosterone replacement, anabolic steroids, or other androgenic compounds?

Yes

History of male-specific surgeries (vasectomy, prostate procedures, testicular surgery)?

Yes

Sleep, Mood, Cognitive
& Neurological

Average sleep duration (hours) / sleep quality

Sleep Duration (Hours)

Sleep Quality

Do you have insomnia, difficulty falling or staying asleep?

Yes

Do you snore, wake breathless, or suspected sleep apnea?

Yes

Do you experience daytime fatigue, cognitive fog, poor memory?

Yes

Do you have history of anxiety, depression, PTSD, OCD, bipolar?

Yes

Are you on psychiatric medications / counseling?

Yes

Do you have migraines, seizures, or other neurological diagnoses?

Yes

Do you experience brain fog, concentration difficulties, or memory decline?

Yes

Musculoskeletal,
Injury & Pain

Do you have chronic pain (joint, back, neck)?

Yes

Any history of muscular tears, tendon injuries, or ligament injuries?

Yes

Have you had orthopedic surgeries or implants (joint replacement, spinal surgery)?

Yes

Do you engage in regular strength / resistance training / athletic activity?

Yes

Have you recently (past 12 months) experienced significant injuries or soft-tissue damage?

Yes

Sleep, Stress &
Immune / Inflammatory

Do you have autoimmune disease or chronic inflammation (e.g. rheumatoid arthritis, lupus)?

Yes

Do you have frequent infections, low immunity, or slow recovery from illness?

Yes

Do you use immunomodulating therapies (e.g. biologics, immunosuppressants)?

Yes

How would you rate stress level (low / moderate / high)?

Low

Moderate

High

Do you practice stress management (meditation, breathing, therapy)?

Yes

Sleep, Stress &
Immune / Inflammatory

Diet Type

Omnivore

Vegetarian

Vegan

Keto

Low-carb

Other

If other, please provide details.

Approximate daily caloric intake / macronutrient breakdown (if known)

Fluid consumption (litres per day)

Sleep hygiene habits (screens, bedtime routine)

Physical activity (Frequency, Type, Intensity)

Use of wearables or continuous monitors

HRV

Sleep Tracker

CGM

Accelerometer

Others

If others, please provide details.

Do you use intermittent fasting, time-restricted eating, or caloric cycling?

Intermittent Fasting

Time-Restricted Eating

Caloric Cycling

None

Supplement regimen

Vitamins

Minerals

Nootropics

Other

If other, please provide details.

Do you consume anti-oxidants, omega-3, etc.?

Yes

Use of cold exposure, sauna, hyperbaric oxygen, red light therapy?

Yes

Safety & Contraindications for Peptide / Emerging Therapies

Do you have allergy / hypersensitivity to any peptides, injectables, or biologic compounds?

Yes

Are you pregnant or breastfeeding (also ask earlier, but re-check)?

Pregnant

Breastfeeding

None

Do you have a history of cancer or malignancy?

Yes

Have you had organ transplant or immunosuppressive therapy?

Yes

Do you have active infection, fever, or sepsis?

Yes

Do you have uncontrolled hypertension or cardiovascular disease?

Yes

Have you had a history of clotting disorders, stroke, or deep vein thrombosis?

Yes

Do you have severe renal or hepatic impairment?

Yes

Do you use anticoagulants or platelet inhibitors?

Yes

Are you currently on any restricted / controlled substances that may interact or be contraindicated?

Yes

Do you have underlying endocrine tumors (pituitary adenoma, adrenal tumor)?

Yes

Do you have uncontrolled diabetes or diabetic complications (retinopathy, nephropathy)?

Yes

Have you had recent major surgery (within 3-6 months)?

Yes

Do you have unhealed wounds or bleeding disorders?

Yes

Do you have any psychiatric instability (psychosis, bipolar mania) that might be exacerbated?

Yes

Diagnostics & Lab / Biomarker Data (This section is fine to be left blank/no upload if pt does not have bloods)

Please upload or report your most recent labs (within past 12 months if available):

CBC (complete blood count)
CMP / comprehensive metabolic panel (liver enzymes, creatinine, electrolytes)
Lipid panel (LDL, HDL, total cholesterol, TG)
Fasting glucose, HbA1c, insulin
Thyroid panel (TSH, free T3, free T4)
Sex hormones (testosterone, estradiol, LH, FSH, SHBG)
Cortisol / adrenal panel
IGF-1, growth hormone (if available)
CRP, ESR, markers of inflammation
Vitamin D, B12, folate
Kidney function & eGFR
Liver enzymes, bilirubin, albumin
Prostate-specific antigen (PSA) for men (if applicable)
Others: homocysteine, lipoprotein(a), ferritin, iron studies, etc.

Drop files here or

Max. file size: 800 MB.

Do you perform continuous or periodic biomarkers (e.g. HbA1c, advanced lipids, metabolomics, genetic testing)?

Yes

Do you wear any continuous monitors (CGM, HRV monitor, wearable trackers)?

Yes

Are you willing to do additional lab tests, imaging, or specialized biomarkers if recommended?

Yes

Goals, Expectations &
Risk Acknowledgement

What are your top 3 health goals (performance, longevity, body composition, cognitive, sleep, libido, etc.)?

Performance

Longevity

Body composition

Cognitive

Sleep

Libido

What is your time horizon and commitment level?

12 weeks

24 weeks

Ongoing

What prior therapies / protocols have you tried (peptides, hormones, supplements)? Outcome?

Are there specific compounds you wish to avoid or are concerned about?

Are there financial or logistical constraints (lab limits, travel, injection comfort)?

Do you agree to follow follow-up protocols, monitoring, reporting side effects, and immediate cessation if red flags arise?

Yes

Do you understand that all emerging therapies, peptides, and treatments carry risks, and that results are not guaranteed?

Yes

Patient Consent Form

Purpose of Treatment

I understand that I am engaging in a telehealth consultation with Lumina Life Sciences, a licensed medical provider operating under DHA guidelines, for the purpose of assessment, diagnosis, and management of my health, hormonal, and longevity-related needs, which may include the prescription of peptide, hormone, or other emerging therapeutic agents.

Nature of Telehealth Services

I acknowledge and consent to receive healthcare services via telemedicine, which involves the use of digital communications to facilitate medical evaluation, diagnosis, prescription, and follow-up.

I understand that:

My clinician may not be physically present during the consultation.
I have the right to request an in-person consultation at any time.
All medical records and data will be securely stored and managed in accordance with Dubai Health Authority (DHA) data protection, privacy, and telehealth standards.
Telehealth may have limitations, including potential interruptions or security risks inherent to digital communications.

Off-Label and Emerging Therapies

I understand that peptide and certain hormone therapies offered by Lumina Life Sciences may be used for “off-label” purposes , meaning they may not be specifically approved by international or UAE regulatory authorities for the indication being treated.

I acknowledge that:

Off-label use is a recognized and lawful medical practice when determined appropriate by a licensed clinician.
My clinician has explained the intended benefits, potential risks, and limitations of such treatments.
These therapies may not have undergone long-term safety studies for all indications.
My participation is voluntary, and I may discontinue treatment at any time.
Lumina Life Sciences does not guarantee specific results or outcomes.

Potential Risks and Side Effects

I have been informed that possible side effects of peptide, hormone, or adjunct therapies may include but are not limited to:

Injection site irritation, redness, or swelling
Nausea, headache, dizziness, fatigue, or mood changes
Hormonal fluctuations (including libido, sleep, or weight changes)
Fluid retention or electrolyte imbalance
Rare allergic or hypersensitivity reactions

I understand that:

All medications and compounds are prescribed and compounded under medical supervision.
I will report any adverse reactions promptly to my clinician.
Emergency medical attention is available if serious side effects occur.

Medical Disclosure

I confirm that:

I have provided a complete and accurate medical history to Lumina Life Sciences.
I have disclosed all current medications, supplements, and pre-existing conditions.
I will notify my clinician of any new symptoms, medications, or diagnoses that arise during treatment.

I understand that:

All medications and compounds are prescribed and compounded under medical supervision.
I will report any adverse reactions promptly to my clinician.
Emergency medical attention is available if serious side effects occur.

Confidentiality & Data Protection

I understand that:

My personal and medical data will be protected under UAE ICT and DHA patient data confidentiality laws.
My data may be shared only with authorized medical professionals involved in my care.
Digital records will be encrypted and securely stored on DHA-approved platforms.

Financial and Treatment Responsibility

I acknowledge that:

I am responsible for all associated treatment and consultation fees.
Compounded medications may not be covered by insurance.
I have had the opportunity to discuss costs and understand all payment terms prior to initiating therapy.

Informed Consent Acknowledgment

I confirm that:

I have read and understood the information provided in this consent form.
I have had the opportunity to ask questions regarding telehealth services, peptide therapy, hormone optimization, and off-label treatments.
My questions have been answered to my satisfaction.
I understand that results vary and are not guaranteed.
I consent voluntarily to participate in this treatment program.

I understand that I am engaging in a telehealth consultation with Lumina Life Sciences, a licensed medical provider operating under DHA guidelines, for the purpose of assessment, diagnosis, and management of my health needs. This includes the promotion of wellness and optimal physical and mental health, and not merely the treatment of disease.

I understand that Lumina Life Sciences provides services including lifestyle advice, supplementation protocols and the prescription of medicines, therapeutic peptides, hormones and other emerging therapeutic agents.

Patient Declaration

I hereby give my informed consent to Lumina Life Sciences and its licensed medical practitioners to:

Conduct telehealth consultations and assessments.
Prescribe and administer peptide and/or hormone therapies where clinically indicated.
Store and use my medical data in compliance with DHA regulations.

Patient Signature:

This field is hidden when viewing the form

Date

MM slash DD slash YYYY

Clinician Signature:

This field is hidden when viewing the form

Date

MM slash DD slash YYYY

Let’s start with your personal information

Consent to telehealth:

General Health & Medical History

Cardiovascular & Metabolic Screening

Hormonal, Reproductive & Sexual Health

For All Patients

Additional for Females

Additional for Males

Sleep, Mood, Cognitive & Neurological

Musculoskeletal, Injury & Pain

Sleep, Stress & Immune / Inflammatory

Sleep, Stress & Immune / Inflammatory

Safety & Contraindications for Peptide / Emerging Therapies

Diagnostics & Lab / Biomarker Data (This section is fine to be left blank/no upload if pt does not have bloods)

Goals, Expectations & Risk Acknowledgement

Patient Consent Form

Purpose of Treatment

Nature of Telehealth Services

Off-Label and Emerging Therapies

Potential Risks and Side Effects

Medical Disclosure

Confidentiality & Data Protection

Financial and Treatment Responsibility

Informed Consent Acknowledgment

Patient Declaration

Supplements

Prescription Solutions

General Health &
Medical History

Cardiovascular &
Metabolic Screening

Hormonal, Reproductive
& Sexual Health

Sleep, Mood, Cognitive
& Neurological

Musculoskeletal,
Injury & Pain

Sleep, Stress &
Immune / Inflammatory

Sleep, Stress &
Immune / Inflammatory

Goals, Expectations &
Risk Acknowledgement