Patient Registration - AS Wellness by Ageing Solutions

At Ageing Solutions we take your health and wellbeing seriously. In order for our Medical Team to provide you with a personalised treatment program and our integrative medical solutions, you will be required to complete our registration process. It is essential that during this process you provide us with your most up to date medical information including any current medications, health concerns and/or injuries, as well as any upcoming and/or past surgeries.

As per Australian Regulations, our Medical Team must have your current medical information before displaying Schedule 4 Medications and Supplements.

We also take your privacy seriously and manage your private information with the utmost care and consideration. We will not pass your details or information onto any third party and our Medical Team will only contact you if you place an order with us.

We thank you for your cooperation and understanding. If you have any questions please do not hesitate to contact our Customer Service Team on 1300 100 490.

Name*

First Name * Last Name *

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email Address*

Username

Password*

Enter Password Confirm Password

I am over 18 years old*

YES

Birth Date*

Sex assigned at birth*

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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.*

To finalise your registration and become a patient with Ageing Solutions, you must read the statements below and agree using the checkbox 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 access to browse and shop our range of supplements, medications and peptides, as well as place an order. Please note patients may be required to complete further medical questionnaires to be able to view and purchase particular schedule 4 medications.

At Ageing Solutions we want you to always be informed. Please read these statements carefully and provide your consent by signing in the text box provided below.

Consent*

MEDICAL CONSENT

To finalise your registration and become a patient with Ageing Solutions, 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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At Ageing Solutions we want you to always be informed. Please read below and sign the consent form in the text box provided.

Our Doctors prescribe a combination of supplements, vitamins and minerals along with scheduled medications which include Peptides.
I understand that Peptides are still classed as research medications and the human data and medical research on these medications are limited. Although Peptides are simply 2 or more amino acids linked together and have been used in anti ageing for over 40 years.

I have completed my personal medical history and enrolment information accurately and truthfully. If anything changes with my health status or medication I agree to inform the team at Ageing Solutions as soon as possible.

I consent to the customer service team contacting me by phone or email to clarify any questions about medical history, product selection and pathology. I understand that the Doctors at Ageing Solutions will review my medical history and ensure that the selected supplements, medications & programs will be best suited to the health goals I am trying to reach. I understand the Doctor will email confirmation once my medical history and product selection has been approved or if there is further information required the Doctor may call to clarify. I understand that a comprehensive long Doctor consultation is available at an extra fee.

I consent to my de identified medical data to be used for future medical research. I understand that this data does not contain any personal information.

I understand that Ageing Solutions does not hold any compounded products or medication on hand and all medications & supplements are compounded as scripted by Australian only sterile compounding pharmacies, medications are sent from the pharmacy directly to you the patient. All medications are compounded ready to use as per Australian Pharmacy Guild guidelines. I understand that the pharmacy ships products directly and I will receive a tracking number on the day it has been shipped, as Ageing Solutions is a third party to the shipment and are unable to track or contact the courier on your behalf.

I agree to inform Ageing Solutions of any adverse reactions to medications or supplements as soon as possible.

I agree to all statements above

Terms & Conditions*

I accept the website terms and conditions

Signature ( please sign below )

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Consent Form Signed Date

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