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Begin Your GLP-1 Journey: Medical History & Consent

Help us get to know you by completing this brief medical history form.


Your information is kept private and will be carefully reviewed by a licensed provider to ensure treatment is safe and appropriate for you.


Before starting the medication, you’ll receive detailed information on how it’s administered and what to expect.

Birthday
Month
Day
Year
Are you male or female?
Male
Female
Multi-line address

(This is required to confirm your identity with our pharmacy partners)

Have you ever taken a GLP-1 medication before? (e.g. Semaglutide, Tirzepatide)
No
Yes
Have you ever been diagnosed with or told you have pancreatitis?
Yes
No
Do you have a history of any of the following?

Be sure to include any medical conditions, including those treated with medications. If none, please enter "none"

Include all medications including supplements that you take daily or frequently. If none, please enter “none”.

List all allergies to medications. If none, please enter “none”.

Are you pregnant, breastfeeding, trying to, or at risk of getting get pregnant?
Yes, I am currently pregnant or breastfeeding
Yes, I am currently trying to become pregnant or having sex without birth control.
No
For your safety you should not take GLP-1s if you're planning on becoming pregnant. It can take up to 6 weeks for GLP-1s to be completely out of your body. If you're planning to become pregnant, stop GLP-1s at least 2 months prior.
I understand
I do not understand
Purging (self-induced vomiting with or without the use of laxatives or diuretics/water pills), severely restriction calorie intake, or falling below a BMI of 18.5 severely increases the risk of electrolyte imbalances and seizures while on treatment.
I understand
I do not understand
Do you have a family history of thyroid issues?
No
Yes
Have you or a family member ever been diagnosed with any of the following conditions?
Have you ever experienced any of the following?
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