PT-141 (Bremelanotide) Intake Form Template
PT-141 (Bremelanotide) is a melanocortin receptor agonist FDA-approved for hypoactive sexual desire disorder (HSDD) in premenopausal women and used off-label for male sexual dysfunction and low libido. It works centrally through the nervous system rather than the vascular system. Due to its transient blood pressure effects, cardiovascular screening is essential before prescribing. This intake form documents sexual health symptoms and evaluates cardiovascular and medication-related contraindications.
Free Template
PT-141 (Bremelanotide) Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
PT-141 (Bremelanotide) 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.
PT-141 (Bremelanotide) is FDA-approved as Vyleesi for HSDD in premenopausal women. Off-label use in men requires informed consent. See FDA labeling: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/210557s000lbl.pdf
PT-141 causes a transient increase in blood pressure averaging 6 mmHg systolic. Patients with uncontrolled hypertension or cardiovascular disease are contraindicated.
PT-141 should not be used concurrently with naltrexone. Review all medications before prescribing.
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Sources & References
Frequently Asked Questions
How does PT-141 work differently from ED medications like sildenafil?
PT-141 acts centrally on melanocortin receptors in the brain to enhance sexual desire and arousal, unlike PDE5 inhibitors (Viagra, Cialis) which work on penile vascular smooth muscle. PT-141 can be effective even when PDE5 inhibitors have failed.
What are the most common side effects of PT-141?
Nausea, flushing, and transient blood pressure elevation are the most common side effects. Nausea typically peaks 30-60 minutes after administration and resolves within a few hours.