Oral GHK-Cu Intake Form Template
GHK-Cu (copper tripeptide-1) is a naturally occurring copper-binding peptide with tissue repair, anti-aging, and anti-inflammatory properties. Oral formulations are available through compounding pharmacies for wound healing support, skin health, and systemic tissue regeneration. This intake form documents skin and healing symptoms and screens for contraindications including active cancer and severe liver or kidney disease.
Free Template
Oral GHK-Cu Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Oral GHK-Cu Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Symptoms
Select all symptoms that currently apply to you.
Symptoms
Select all symptoms that currently apply to you.
4 Contraindications
Select all conditions that currently apply to you.
Contraindications
Select all conditions that currently apply to you.
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Oral GHK-Cu is not FDA-approved and is compounded off-label. Informed consent is required. See FSMB: https://www.fsmb.org
GHK-Cu must be dispensed by a licensed compounding pharmacy. See FDA: https://www.fda.gov/drugs/human-drug-compounding
Want This Form Automated?
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- Branded intake on your website
- AI contraindication screening
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- Automated refill management
- E-signatures and HIPAA audit trail
- 50-state provider network included
Free 30-minute walkthrough
Sources & References
Frequently Asked Questions
How is oral GHK-Cu different from topical or injectable GHK-Cu?
Oral GHK-Cu is formulated for systemic absorption through the GI tract. While topical forms are used primarily for skin and scalp applications, oral formulations are intended for broader systemic tissue repair and anti-aging benefits.
Is GHK-Cu safe for long-term use?
GHK-Cu has a favorable safety profile based on existing research. As with all off-label therapies, long-term safety data in large human populations is limited. Patients should be monitored for response and any adverse effects.