Pure Alchemy Wellness:
Get Started

Welcome to your personalized wellness journey.

Please complete the form below so our clinical team can safely build a custom treatment plan tailored to your health history, goals, and lifestyle.

Step 1: Basic Information

Let’s get to know you..
Your answers help us determine eligibility and customize your care. .

First Name

Last Name

Sex Assigned at Birth

Date of Birth

Email Address

Phone Number

Step 2: Physical Details

Height (Feet + Inches)

Weight (lbs)

Display BMI

Step 3: Medical History – Conditions Checklist

Step 4: Medications, Conditions, & Allergies

Current medical conditions

All current medications (include dosages)

Any known allergies

Step 5: Current GLP-1 Use

Are you currently taking a GLP-1 medication such as Semaglutide (Ozempic/Wegovy) or Tirzepatide (Mounjaro/Zepbound)?

Yes No

Step 6: Pregnancy & Breastfeeding Status

Are you currently pregnant, breastfeeding, or planning to become pregnant?

Step 7: Upload Identification & Labs

Upload a valid photo ID

Upload recent labs (optional)

Step 8: Informed Consent – GLP-1s, Peptides, NAD+

Please read and acknowledge the following before proceeding.

Potential Benefits:

Appetite control or fat loss

Increased energy and cognitive clarity

Better sleep, libido, and mood

Enhanced recovery and anti-aging support

Potential Risks:

Nausea, headaches, GI upset

Hormonal or metabolic effects

Allergic reaction

Fatigue or flu-like symptoms

I understand that some therapies may be prescribed off-label. I understand the potential risks and benefits. I consent to treatment.

Step 9: Truthfulness Certification

I confirm all information is accurate and complete.

Step 10: Shipping Address

Street Address

City

State / Province

ZIP / Postal Code

Step 11: Secure Payment

Submit the form to proceed to the payment page.

Total: $X.XX

I agree to the Terms of Service and Privacy Policy.

Testimonials

See What Our Clients are Saying

“The number one wellness bar in Southern California, Kay Is kind and Professional and knowledgeable about all The treatments she has available. I was completely hung over headache and bodyaches from A party The night before and it all went away.”

Robert, CA

"Kay is professional, well educated & very welcoming. All my concerns were addressed with kindness and patience"

Maggie, CA

“Best hydration IV clinic near me. I had the B12 shot for weight loss and energy. Kay was knowledgeable and friendly. Happy to have this service available close by. Will be back”

Kemi, CA

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FDA Statement: These statements have not been evaluated by the Food and Drug Administration. This product/service is not intended to diagnose, treat, cure, or prevent any disease.