Bio Hacking Luxe Membership Enrollment Form

Welcome to Bio Hacking Luxe — where science meets luxury wellness.
Please complete the form below to see if you qualify begin your membership.
All information is HIPAA-protected and confidential.

1. Personal Information

First Name

Last Name

Phone Number

Date of Birth

Age

Sex

Shipping Address (Street, City, State, Zip):

Emergency Contact Name:

Relationship

Phone Number

2. Membership Selection
🧬 Bio Hacking Luxe Membership – $199/month

Transform your health and performance with personalized white glove
concierge precision.
The Bio Hacking Luxe Membership provides a comprehensive foundation
for optimizing your hormones, peptides, and overall wellness—all
designed to help you look, feel, and perform at your best.

Membership Includes:

Personalized hormone, peptide, and wellness consultation
Ongoing medical support from licensed professionals
Access to hormone, peptide, and injectable vitamin therapy refills
Member-only pricing on all therapies and genetic testing kits
Complimentary wellness check-ins every 90 days
Direct messaging access to your concierge coordinator
Exclusive invitations to hotel-based wellness retreats and events

Why Patients Choose This Membership:
Experience science-driven, concierge-level care that helps you
increase energy, balance hormones, improve sleep, boost libido,
enhance mood, and elevate overall performance—without the guesswork.

3. Health & Wellness Goals

What are your top 3 wellness goals

Weight loss

Energy optimization

Sexual wellness

Muscle gain / body composition

Cognitive enhancement

Longevity / anti-aging

Stress resilience

Mental clarity / mood balance

Sleep optimization

Other

Describe your current health and wellness routine (diet, exercise, supplements, etc.)

Have you previously done hormone or peptide therapy?

Yes

If Yes Please Describe

4. Medical Information

Current Medications or Supplements:

Allergies:

Do you have any diagnosed medical conditions?

Do you currently work with a physician or wellness practitioner?
If yes, name & specialty:

Do you currently work with a physician or wellness practitioner?If yes, name & specialty:

Yes

5. Payment Authorization

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I authorize Bio Hacking Luxe to charge my preferred payment method monthly for the membership tier selected above.

I understand that membership renews automatically each month unless canceled in writing with 30 days’ notice.

I acknowledge that all treatments and recommendations are based on personalized testing results, and outcomes may vary.

Payment Method

Credit/Debit Card

ACH

Other

Signature

Date

6. Agreement & Consent

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I confirm that all information provided is accurate to the best of my knowledge.

I acknowledge that Bio Hacking Luxe does not diagnose, treat, or cure medical conditions.

I consent to lab testing, treatment protocols, and communications from Bio Hacking Luxe regarding my wellness plan.

I agree to the Terms of Service, Privacy Policy, and HIPAA Notice.

Signature

Date

7. Concierge Contact Preferences

Untitled multiple choice field

Call

Text

Preferred Time To Contact

Morning

Afternoon

Evening