Start Your Journey - Oak Longevity Institute

Step 1 of 8

Welcome to Oak Longevity Institute

Let’s start with your basic information. All data is HIPAA-compliant and confidential.

First Name *

Please enter your first name

Last Name *

Please enter your last name

Date of Birth *

Please enter your date of birth

Sex Assigned at Birth *

Please select your sex

Email Address *

Please enter a valid email address

Phone Number *

Please enter your phone number

State of Residence *

Oak Longevity currently serves patients in select states. Illinois residents receive priority scheduling.

Please select your state

What Brings You In Today?

Select all treatment areas that interest you. Your physician will review each selection and design a personalized protocol.

⚖

Weight Management

Semaglutide (GLP-1 therapy)

⚛

Peptide Therapy

BPC-157, TB-500, Sermorelin

⚗

Hormone Optimization

Testosterone, DHEA, Pregnenolone

∞

Longevity Medicine

Rapamycin, Metformin, NAD+

♥

Sexual Health

PT-141, Testosterone therapy

★

Immune Support

Thymosin Alpha-1, Glutathione

Please select at least one treatment area

Medical History

Please list all current medications, allergies, and medical conditions. This information is critical for safe prescribing.

Current Medications

Include prescription medications, over-the-counter drugs, and supplements

Known Allergies *

Please list allergies or type NKDA

Current Medical Conditions *

Select all that apply:

Diabetes (Type 1 or Type 2)

High Blood Pressure

Heart Disease / Cardiovascular Disease

Cancer (current or history)

Thyroid Disorder

Kidney Disease

Liver Disease

Autoimmune Disorder

Blood Clotting Disorder / History of DVT/PE

Depression / Anxiety / Mental Health Condition

None of the above

Past Surgeries

Family History

Vitals & Lifestyle

These measurements help us determine appropriate dosing and identify potential risk factors.

Height *

Please enter your height

Weight (lbs) *

Please enter your weight

Blood Pressure (if known)

Resting Heart Rate (if known)

Exercise Frequency *

Average Sleep per Night *

Alcohol Consumption

Tobacco / Nicotine Use

Safety & Contraindication Screening

These questions are essential for your safety. Please answer honestly so our physician can prescribe safely.

Important: Answering “yes” to any of these does not automatically disqualify you. Our physician will review your complete profile and determine the safest treatment approach.

Are you currently pregnant, breastfeeding, or planning pregnancy?

Personal or family history of medullary thyroid carcinoma (MTC) or MEN2 syndrome?

Important for GLP-1 (Semaglutide) prescribing

History of pancreatitis?

Important for GLP-1 (Semaglutide) prescribing

History of prostate cancer or breast cancer?

Important for testosterone/hormone therapy

History of polycythemia (elevated red blood cell count)?

Important for testosterone therapy

Active cancer or currently receiving cancer treatment?

Important for peptide therapy (growth factors)

Currently immunosuppressed or on immunosuppressive medications?

Important for Rapamycin prescribing

Active serious infection?

Important for Rapamycin and peptide therapy

Uncontrolled high blood pressure (systolic above 160)?

Important for PT-141 and stimulant medications

Severe kidney disease (eGFR below 30)?

Important for Metformin prescribing

None of the above apply to me

Health Goals & Expectations

Help us understand what you hope to achieve so we can tailor your protocol.

Primary Health Goals *

Please describe your health goals

Have you tried any treatments before?

Anything else our physician should know?

Consent & Agreements

Please review and acknowledge the following before submission.

I consent to receiving telehealth medical services

I understand that my consultation will be conducted via telehealth (phone/video) and that I will be evaluated by an Illinois-licensed physician.

I certify the information provided is accurate and complete

I understand that providing inaccurate medical history could affect the safety of my treatment.

I understand medications require physician approval

I understand that all prescriptions are at the sole discretion of the treating physician after review of my health profile, and that the physician may recommend alternative treatments.

I acknowledge the Privacy Policy and Terms of Service

My health information will be stored securely in compliance with HIPAA regulations and will only be shared with my treating physician and pharmacy.

Electronic Signature *

By typing your name, you are providing your electronic signature.

Please type your full name as signature

Today’s Date

Your Health Summary

Based on your responses, here is your preliminary assessment. Our physician will review and finalize your personalized protocol.

Patient Information

Recommended Protocol for Physician Review

The following recommendations are generated based on your health profile and treatment interests. Your physician will review, modify, and finalize your protocol during your consultation.

What Happens Next?

Physician Review
Dr. Schmidt and our medical team will review your complete health profile within 24-48 hours.

Telehealth Consultation
You’ll be contacted to schedule a telehealth visit to discuss your protocol and answer any questions.

Prescription & Fulfillment
Approved medications will be prescribed and shipped directly from our licensed compounding pharmacy to your door.

✓

Intake Form Submitted Successfully

Thank you for completing your health assessment. Our physician team will review your profile and contact you within 24-48 hours to schedule your consultation.

A confirmation has been sent to your email address. If you have any questions in the meantime, please contact us at info@oaklong.com