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Contact Us

HQ – NSW Office:

Level 13 Suite 1A, 465 Victoria Ave,
Chatswood
NSW
2067

Head Office – NSW Office
QLD Office:

Level 2/194 Varsity Parade, Varsity Lakes
QLD
4227

Queensland Office
Email:

admin@theicb.com.au

Phone:

02 8001 6558

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Muscle Bulk

Peptide Program Registration

Please register your details to have one of our consultants come back to you with pricing and other relevant information. We look forward to assisting you with your health goals.

Personal Details
  
My CLINIC / AGENT IDENTIFIER

GP Information (optional)

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Additional Information

Growth Hormone Peptide Medical Questionnaire

This Medical Questionnaire is designed to ensure that it is safe for you to commence a program of growth hormone (GH) secreting peptides. GH peptides and GH treatment have been proven to be safe and very effective, provided certain diseases are not present, overdoses are not consumed and possible side effects are checked. Please complete the requested sections and follow the prompts.

Yes    No

Please select your objective(s) *

     
     
     
     
     
     
     
     
     

Current High Risk Symptoms
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No

Current Medical History
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No
Yes    No

Past Medical History
Yes    No
Yes    No
Yes    No
Yes    No

Medications
Yes    No
Yes    No

Allergies
Yes    No
Yes    No

Muscle Definition
Weight Loss–Aggressive
Weight Loss–Moderate
Age Rejuvenation
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