Patient Intake Form

This form collects medical information to help our clinicians determine whether a consultation at Regen Institute may be appropriate for you. Please note Regen Institute is a fully private service with no medicare rebate available.

Please complete all questions honestly and accurately. Incomplete or inaccurate information may affect your eligibility for treatment and your safety.

PRIVACY NOTICE

Regen Institute Pty Ltd (ABN 68 781 484 848) collects your personal and sensitive health information to assess your suitability for consultation, provide medical care, arrange investigations, and communicate with you and relevant providers. If you do not provide this information, we may be unable to proceed with your care. Your information may be disclosed to clinicians involved in your care, pathology providers, pharmacies, your treating practitioners, and service providers who support our systems, as permitted by law. Our Privacy Policy explains how we handle your information, including access, correction, and complaints: https://www.regeninstitute.com.au/privacypolicy. By proceeding, you acknowledge this collection and our Privacy Policy.

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PATIENT DETAILS

First Name *

Last Name *

Preferred Name

Date of Birth *

Sex at Birth *

MaleFemale

Gender

MaleFemaleNon-binaryPrefer not to say

PATIENT CONTACT DETAILS

Home Phone

Mobile Phone *

Work Phone

Email *

Address Line 1 *Street address line 1 only. eg 123 Citizen Street

Postcode *

City / Suburb *

State *

ELIGIBILITY SCREENING

To proceed with booking, please confirm the following:

I am 18 years of age or older
I am not currently pregnant
I am not breastfeeding
I am not attempting to conceive
I am not a professional athlete or subject to WADA anti-doping testing *

TISSUE/INJURY RECOVERY AND REPAIR

Presenting Issue

What is the main reason you are looking to book in Regen Institute for? *

Was the injury/issue? *

Acute (less than 6 weeks ago)Sub Acute (between 6 to 12 weeks ago)Chronic (greater than 3 months)

If Other, please explain

MEDICAL HISTORY

Please list your past and current medical conditions? *

Please list any surgeries you have had in the past *Please include details and the approximate date of each of procedure

Please list all medications and supplements you currently take *Including prescription medications, over-the-counter medications, supplements, hormones or peptides

Do you have any allergies? *If yes, please list them

Do you have any medical conditions that run in the family? *If yes, please list who they are in relation to you and what condition it is. Eg. Cancer, cardiovascular disease, diabetes, autoimmune disorders, thyroid disease

SOCIAL HISTORY

What do you do for work? *

Who do you live with at home? *

Do you drink alcohol? *

Which of the following best describes your cigarette smoking status? *

Non-smokerCurrent smokerEx-smokerOccasional amoker

How many cigarettes do you smoke per day?

How long have you been smoking for?

PREVIOUS EXPERIENCE WITH PEPTIDE THERAPY?

Have you ever previously used peptide therapy for tissue repair/recovery? *

YesNo

If Yes, please list

ADDITIONAL INFORMATION

Is there anything else you would like your doctor to know before your consultation? *

IF YOU HAVE A REFERRAL (PLEASE FILL IN THIS SECTION)

Referring Doctor/Allied Health Professional Name

Clinic

Regular General Practitioner Name (if different to referring doctor) *

Clinic *

If you have a referral or supporting documentation please attach them here

Browse

Attach a referral, diagnostic imaging, pathology, health care summary or any other supporting documentation

MEDICARE

Full Name on Medicare Card (exactly how it appears on card) *If you do not have a medicare card, please contact the clinic at support@regeninstitute.com.au

Medicare Card No. *

Medicare IRN (Individual Reference Number) *

Medicare Expiry *Required format: YYYY-MM (e.g 2026-03)

EMERGENCY CONTACT DETAILS

Name

Address

Postcode

City / Suburb

State

Home Phone

Mobile Phone

Email

Work Phone

IMPORTANT DECLARATIONS

Before proceeding please confirm the following:

I agree to report any side effects or adverse reactions to Regen Institute as soon as possible. *

I understand that if I experience serious or concerning side effects, I must stop the medication immediately and seek urgent medical attention. *

I acknowledge that any medication prescribed by Regen Institute is for my personal use only. *

I confirm that I have fully disclosed my past medical history, including any history of:
- Cancer
- Prostate Disease
- Diabetes
- Thyroid Disorders
- Heart Disease
- Liver Disease
- Kidney Disease
- Complex mental health conditions
- Or any other serious medical conditions *

I confirm to keep all my health professionals up to date on my treatment. *

I understand that Regen Institute does not replace my regular GP and is not intended to provide comprehensive primary care. *

SIGNATURE

By completing this form, you confirm you have read, understood and consent to our terms of service, privacy policy and terms and conditions. I confirm the following:

I have answered all questions honestly and accurately to the best of my knowledge. *

I understand that providing incomplete or inaccurate information may affect my care and eligibility for treatment. *

I consent to Regen Institute collecting and using my information for clinical assessment and treatment planning. *

I consent to Regen Institute using AI-assisted documentation tools to support note-taking during my care. Clinical decisions remain the responsibility of my treating doctor. Further details about how these tools handle information are set out in the Privacy Policy

I provide consent for Regen Institute to review my My Health Record where clinically appropriate *

I provide consent for Regen Institute to communicate with my primary care provider or other treating clinicians if necessary for safe treatment

I provide consent for Regen Institute to contact me regarding appointments, clinical care and act as a payment agent to co-ordinate the supply of my medicine where appropriate. *

Patient Signature *

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