Regenerative & Wellness Consultation Intake — Lumina Regenerative Sciences

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About you

So the clinic knows who you are and how to reach you.

First name*

Last name*

Email*

Mobile phone*

Date of birth*

City and state

Best way to reach you*

Text messagePhone callEmail

How did you hear about Lumina?

Google searchInstagramFriend or familyAnother providerOther

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Your goals

What you want from the consultation. The doctor builds the plan around this.

Which of the five key areas are you interested in?*

Mitochondrial RejuvenationPhysical Performance EnhancementGut Biome OptimizationMetabolic Weight Loss TherapyRestorative Skin, Hair & Facial AestheticsNot sure — help me decide

Choose everything that applies — the consultation narrows it down.

What are you hoping to work on?*

Energy & fatigueRecovery & injury supportAthletic performanceMuscle & body compositionWeight lossWeight gain / building lean massDigestion — bloating or IBS / IBD symptomsReflux / GERD symptomsGut biome (microbiome) analysisSleepCognition & focusHealthy aging / longevityImmune supportLibido / sexual healthSkin, hair, or facial concernsOther

What would you like to improve, and/or is there a goal or date you’re working toward?

Preferred pace*

Gradual (8–12+ weeks)Faster (4–8 weeks)Not sure — guide me

What have you already tried for these goals?

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Weight & body

Used to screen safely, dose appropriately, and plan metabolic care.

Height*

Current weight (lb)*

Body fat %, if known

How has your weight changed over the last 12 months?*

StableGained weightLost weightUp and down

About how much, and was it intended?

Describe the pattern

Weight goal*

Lose weightGain weight or lean massMaintain — improve compositionNo weight goal

Sex assigned at birth

FemaleMalePrefer not to say

Relevant to dosing and screening.

Have you had a DEXA body-composition scan?*

Yes — within 12 monthsYes — olderNo

Recent blood work?*

Yes — within 6 monthsYes — olderNo

Please don’t attach files here — the clinic will request them through its secure system.

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Digestive health

Gut biome optimization starts here. Answer what applies; skip what doesn’t.

Do any of these apply to you?*

Bloating or abdominal discomfortDiagnosed IBD (Crohn’s disease or ulcerative colitis)IBS (irritable bowel syndrome)GERD / acid reflux symptomsConstipation or diarrheaFood sensitivities or intolerancesNone of these

Who manages your IBD care, and what treatment are you on?

How often do reflux symptoms occur, and what do you take for them?

When is the bloating worst, and what seems to trigger it?

Would you like a gut biome (GI microbiome) analysis?*

YesMaybe — tell me more at the consultationNo

A stool-based analysis the doctor can order where appropriate.

Have you had GI testing before?

Endoscopy or colonoscopyStool or microbiome testingFood-sensitivity testingBreath testing (SIBO)None

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Medical history

Everything here stays between you and the clinical team.

Do any of these apply to you?*

Diabetes or prediabetesThyroid conditionHeart or blood pressure conditionKidney or liver conditionHistory of pancreatitisCancer (current or past)Autoimmune conditionG6PD deficiencyMental health conditionHistory of an eating disorderNone of these

Current medications and supplements*

Allergies*

Pregnancy status*

Not applicableNoPregnantBreastfeedingTrying to conceive

Surgeries, hospitalizations, or significant injuries

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Treatment experience

No experience needed — this just helps the doctor meet you where you are.

Have you used peptides before?*

NoYes — currentlyYes — in the past

Which peptides, at what dose and frequency?

Which peptides, and how did it go?

Have you had IV therapy before?*

NoYes

What kind, and any reactions?

Comfortable with small self-administered injections?*

YesNoUnsure — tell me more

Some protocols use tiny subcutaneous injections; others use nasal or oral forms.

Preferred forms

InjectionNasal sprayOralIV in clinicNo preference

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Anything else

Questions, concerns, or context for the doctor.

Anything you’d like the doctor to know before your consultation?

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Consent

Please confirm each statement.

The information I’ve provided is accurate and complete to the best of my knowledge.I understand this intake is not a diagnosis or a treatment plan, and that eligibility for any treatment is determined by the physician at a consultation.I understand that eligibility for peptide protocols, IV therapy, and weight-management medications is decided by the physician after screening, and that some answers may mean a treatment isn’t recommended for me.I consent to be contacted by Lumina Regenerative Sciences by phone, text message, or email about my inquiry. Message and data rates may apply; reply STOP to opt out of texts.I have read the Privacy Policy and understand this form is submitted to the clinic’s secure intake system.

Submitted directly to the clinic’s secure, HIPAA-compliant intake system. This website does not store your answers.

Thank you.

Your Regenerative & Wellness Consultation Intake has been sent to the clinic’s secure system. The clinic typically reaches out within one to two business days to schedule your consultation.

Back to the site

Tell the doctor about you and your goals.