Regenerative Medicine — Care Coordinator Intake

About you

A care coordinator will use this to follow up within 24 hours.

First name Last name Email Phone Date of birth Biological sex

Mailing address (for follow-up materials)

Street address Apt / Suite (optional) City State ZIP

What are you trying to address?

Pick the indication closest to your situation. The care coordinator will match you to the right protocol — peptide stack, RPA, or other regenerative arm.

Primary target indication Joint repair / chronic joint pain / post-injury recovery Cognitive resilience / mild cognitive concerns / brain healthspan Already diagnosed (MCI, early dementia, Parkinson's, post-stroke) Acute post-injury repair (tendon, ligament, soft tissue) Athletic performance / recovery / longevity-driven General anti-aging / healthspan optimization Other / multiple

Briefly describe what you're hoping to accomplish (target outcomes, timeline, what you've already tried) If applicable, when was your diagnosis or injury? (optional)

Health background

Quick screen so the care coordinator can route you correctly and the physician has the context they need.

Height (feet) Height (inches) Current weight (lbs)

Prior regenerative therapy (peptides, PRP, stem cells, exosomes, RPA, etc.) — what have you tried?

Active cancer diagnosis or treatment in the past 5 years?

⚠ Most growth-factor-stimulating peptides are contraindicated with active or recent malignancy.

No Yes In remission > 5 years

Diagnosed autoimmune condition? No Yes Unsure

Current medications (include dose if known) Drug or food allergies Anything else the care coordinator should know? (optional)

Save your payment method

⚡ No charge today. Your card is saved securely with Stripe. Regenerative protocols are per-treatment custom pricing — we only charge after the care coordinator provides your written quote and you approve it. No approval, no charge. We ask up front because a physician consult and evaluation have real cost, and a card on file confirms you're a serious candidate.

By continuing you authorize My4MLife and the care coordinator to charge this saved payment method for the regenerative protocol you approve after your consult. You can cancel anytime by emailing support@my4mlife.com.

Review and submit

Confirm everything looks right. After submission, our care coordinator will email you within 24 hours with a personalized quote, protocol recommendation, and scheduling options.

No charge today — your card is on file. Regenerative protocols are per-treatment custom pricing. The care coordinator will provide a written quote after reviewing your intake; nothing is charged until you approve that quote.

I attest the information above is accurate to the best of my knowledge. I authorize My4MLife and the care coordinator to contact me by email or phone to discuss protocol options and pricing. I acknowledge I have received and reviewed My4MLife's Notice of Privacy Practices. I authorize My4MLife and its network physicians to use and disclose my health information to provide, coordinate, and bill for my care, including forwarding my intake to the telemedicine provider, as described in the Patient Authorization & Telehealth Consent.

✓

Your intake is in.

Your card is saved securely — no charge has been made. Our care coordinator will email you within 24 hours with a personalized quote, protocol recommendation, and scheduling options. Nothing is charged until you approve your quote.

Questions? Email support@my4mlife.com.

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Let's get you matched with the right protocol