Melanotan II Peptide Screening Form Template
Melanotan II is a synthetic analogue of alpha-melanocyte-stimulating hormone (alpha-MSH) that stimulates melanogenesis, resulting in increased skin pigmentation. It is prescribed off-label through compounding pharmacies for photoprotection and tanning support. Due to its activity on melanocortin receptors, careful dermatologic and cardiovascular screening is essential before prescribing. This form documents tanning and pigmentation symptoms while screening for dermatologic and cardiovascular contraindications.
Free Template
Melanotan II Peptide Screening Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Melanotan II 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.
Melanotan II is not FDA-approved and is prescribed off-label. Documented informed consent is required. See FSMB: https://www.fsmb.org
A history of melanoma or skin cancer is an absolute contraindication. All patients should have a baseline dermatologic evaluation and mole mapping recommended before initiating therapy.
Melanotan II can cause nausea, facial flushing, and erections as common side effects. Cardiovascular patients require additional evaluation.
Melanotan II 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
Is Melanotan II safe for patients with moles?
Patients with atypical moles, a history of changing moles, or personal/family history of melanoma should be evaluated by a dermatologist before considering Melanotan II. Baseline dermatologic photography is often recommended.
What side effects should patients expect from Melanotan II?
Common side effects include nausea, facial flushing, fatigue, spontaneous erections (in males), and increased libido. These often diminish with continued use. Patients should be counseled on all expected effects before starting.