GHK-Cu / Epithalon Peptide Screening Form Template
GHK-Cu (copper peptide) and Epithalon are often combined in longevity and regenerative medicine protocols. GHK-Cu supports tissue repair, wound healing, hair and skin quality, and immune modulation, while Epithalon provides sleep support, pineal regulation, and telomere-related anti-aging benefits. This screening form captures the full symptom and contraindication profile for patients being evaluated for this combination therapy.
Free Template
GHK-Cu / Epithalon Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
GHK-Cu / Epithalon Peptide Screening 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 Medical Conditions
Select all conditions that currently apply to you.
Medical Conditions
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.
Both GHK-Cu and Epithalon are prescribed off-label. Informed consent should list each peptide individually. See FSMB: https://www.fsmb.org
GHK-Cu may have immunomodulatory effects. Patients with autoimmune conditions should be evaluated carefully before initiating therapy.
All peptides must be dispensed by a licensed compounding pharmacy. See FDA: https://www.fda.gov/drugs/human-drug-compounding
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Sources & References
Frequently Asked Questions
What is GHK-Cu used for in clinical practice?
GHK-Cu (copper tripeptide-1) is used off-label for tissue repair, wound healing, skin quality, hair growth, and immune modulation. It is available in both topical and injectable forms through compounding pharmacies.
Why combine GHK-Cu with Epithalon?
The combination addresses both regenerative and longevity goals simultaneously: GHK-Cu supports tissue and cellular repair while Epithalon targets sleep quality and telomere-related aging mechanisms.