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Men’s Full Health Panel
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400.00
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Women’s PCOS Full Panel
$
450.00
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Men’s Baseline Panel
$
350.00
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Women’s PCOS Baseline Panel
$
500.00
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Male Hormone Panel
$
225.00
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Men’s Follow-Up Panel
$
225.00
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Private: System Cleanse
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Women’s PCOS Follow-Up Panel
$
300.00
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Women’s Post-Menopause Full Panel
$
275.00
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Female Hormone Panel
$
225.00
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Women’s Post-Menopause Follow-Up Panel
$
225.00
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Insulin Resistance Panel
$
150.00
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Starter Kits
Hair + Skin Care Starter Kit
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Hormone Balance Starter Kit
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Strength + Endurance Starter Kit
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Focus + Reset Starter Kit
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Gut Health Starter Kit
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Weight Loss Starter Kit
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Weight Loss
GLP-1R
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Basic B Complex
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5-Amino 1 MQ
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Tesofensine
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GLP – 1T
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GLP – 1S
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Advanced Digestive Enzymes
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Strength + Endurance
Tesamorelin / Ipamorelin Stack
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Tesamorelin / MGF / Ipamorelin Stack
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Zinc Picolinate – 30 mg
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ResveraCel
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PolyResveratrol-SR
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Multi-Vitamin Elite A.M. & P.M.(2 bottles)NSF Certified for Sport
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Methyl-Guard
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Lysine
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Iron Bisglycinate
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Creatine (16oz.)
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CoQ10
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IGF-1LR3
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HGH
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cjc-1295/ipamorelin
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Sermorelin
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Basic B Complex
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Hair + Skincare
GHK-cu
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Hair
Stress Adaptogen MD
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Hairbiotic MD
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Hair
DHT Inhibitor MD
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Hair
Nutrafol Men
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Hair
Nutrafol Women
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Skin Care
Triple Lipid Restore 2:4:2
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Skin Care
Retinol 1.0
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Skin Care
Retinol 0.5
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Skin Care
Retinol 0.3
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Skin Care
Resveratrol B E
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Skin Care
P-TIOX
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Skin Care
Hyaluronic Acid Intensifier Multi-Glycan
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Skin Care
Cell Cycle Catalyst
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Skin Care
Glycolic 10 Renew Overnight
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Skin Care
Gentle Cleanser
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Skin Care
Discoloration Defense
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Skin Care
C E Ferulic
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Skin Care
Blemish + Age Defense
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Skin Care
AOX+ Eye Gel
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Gut Health
Thymosin Beta (TB500)
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Thymosin Alpha
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GHK-Cu/BPC-157/TB-500 Stack
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BPC157/TB500 Stack
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Women’s Daily Probiotic
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Trace Minerals
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Super EPA425 mg EPA with 270 mg DHA
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Multi Enzyme
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Liver Cleanse
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L-Glutamine Powder
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L-Glutamine
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GI Relief
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FloraMend Prime Probiotic
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FiberMend
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Daily Greens Plus
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Curcumin Phytosome – 1000 mg
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Boswellia Phytosome
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Berberine – 1000 mg
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5-MTHF 5 mg
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BPC157
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Focus + Reset
Thymosin Beta (TB500)
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Thymosin Alpha
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GHK-Cu/BPC-157/TB-500 Stack
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BPC157/TB500 Stack
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NAD+
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MOTS-c
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Test Product
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PharmaGABA-250
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Melaton-5
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Magnesium Bisglycinate
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Glycine
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Peptide
Thymosin Beta (TB500)
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Thymosin Alpha
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Tesamorelin / Ipamorelin Stack
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Tesamorelin / MGF / Ipamorelin Stack
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GHK-Cu/BPC-157/TB-500 Stack
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BPC157/TB500 Stack
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NAD+
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MOTS-c
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GLP-1R
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GHK-cu
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PT-141
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PE22-28
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IGF-1LR3
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HGH
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cjc-1295/ipamorelin
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Sermorelin
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BPC157
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5-Amino 1 MQ
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Tesofensine
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GLP – 1T
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BHRT
Low Dose Naltrexone
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Thyroid (T3/T4 support)
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Progesterone
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Estradiol
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DHEA
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Testosterone
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Advanced Testing
Blood Panel Review
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Rx
Male Hormone Panel
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Rx
Female Hormone Panel
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Rx
Women’s Post-Menopause Follow-Up Panel
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Rx
Women’s Post-Menopause Full Panel
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Rx
Women’s PCOS Follow-Up Panel
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Rx
Women’s PCOS Baseline Panel
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Rx
Women’s PCOS Full Panel
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Rx
Insulin Resistance Panel
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Rx
Men’s Follow-Up Panel
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Rx
Men’s Baseline Panel
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Rx
Men’s Full Health Panel
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We’ll tailor our suggestions based on your goals, health needs, and preferences. (required for RX products)
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6'6"
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6'10"
6'11"
7'0"
7'1"
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7'3"
7'4"
7'5"
7'6"
7'7"
7'8"
7'9"
7'10"
7'11"
8'0"
8'1"
8'2"
8'3"
8'4"
8'5"
8'6"
8'7"
8'8"
8'9"
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8'11"
Current Weight (Lbs)
Weight Goal (Lbs)
Lifestyles Interested in
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Health Goals
Health Concerns
Lifestyle
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Workout Routine
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3-5 Days
5+ Days
How do you specifically want ELMNTL to help you achieve your peak potential?
I understand and agree that: 1. I am voluntarily providing my health and personal information to ELMNTL for the purposes of wellness optimization, functional medicine analysis, and/or related services. 2. My information will be handled with strict confidentiality and in accordance with HIPAA regulations and all applicable data privacy laws. 3. The services provided by ELMNTL are not a substitute for medical care by a primary care physician or specialist. 4. Any recommendations made are for educational, lifestyle, and performance purposes and are not intended to diagnose, treat, or cure any medical condition unless explicitly directed by a licensed provider. 5. I certify that the information I provide is true and accurate to the best of my knowledge and I am submitting it willingly and without coercion. 6. I have read and understand this disclaimer and agree to proceed.
I consent to ELMNTL collecting and using my information for wellness and functional health services.
I acknowledge that this information will be protected under HIPAA compliance.
I understand ELMNTL does not replace my primary medical care provider and that all services are wellness-focused.
I confirm that the information I provide is accurate and that I am submitting this form voluntarily.
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Consultation
Let’s Get to Know You
We’ll tailor our suggestions based on your goals, health needs, and preferences. (required for RX products)
First Name
Last Name
Email
Birth Date
Sex assigned at Birth
Select One
Male
Female
Current Height (Feet)
4'0"
4'1"
4'2"
4'3"
4'4"
4'5"
4'6"
4'7"
4'8"
4'9"
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
7'1"
7'2"
7'3"
7'4"
7'5"
7'6"
7'7"
7'8"
7'9"
7'10"
7'11"
8'0"
8'1"
8'2"
8'3"
8'4"
8'5"
8'6"
8'7"
8'8"
8'9"
8'10"
8'11"
Current Weight (Lbs)
Weight Goal (Lbs)
Lifestyles Interested in
Hormone Balance
Strength + Endurance
Focus + Reset
Gut Health
Weight Loss
Hair + skin Care
Health Goals
Health Concerns
Lifestyle
Active
Moderate
Sedentary
Workout Routine
0 Days
1-3 Days
3-5 Days
5+ Days
How do you specifically want ELMNTL to help you achieve your peak potential?
Informed Consent & Medical Disclaimer
Please review and confirm the following before submitting your intake form:
I understand and agree that:
1. I am voluntarily providing my health and personal information to ELMNTL for the purposes of wellness optimization, functional medicine analysis, and/or related services. 2. My information will be handled with strict confidentiality and in accordance with HIPAA regulations and all applicable data privacy laws. 3. The services provided by ELMNTL are not a substitute for medical care by a primary care physician or specialist. 4. Any recommendations made are for educational, lifestyle, and performance purposes and are not intended to diagnose, treat, or cure any medical condition unless explicitly directed by a licensed provider. 5. I certify that the information I provide is true and accurate to the best of my knowledge and I am submitting it willingly and without coercion. 6. I have read and understand this disclaimer and agree to proceed.
I consent to ELMNTL collecting and using my information for wellness and functional health services.
I acknowledge that this information will be protected under HIPAA compliance.
I understand ELMNTL does not replace my primary medical care provider and that all services are wellness-focused.
I confirm that the information I provide is accurate and that I am submitting this form voluntarily.
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