GLP-1 / GLP-2 Medical Intake Form

Welcome to Our Medical Intake Process

This form will help us understand your medical history and treatment goals for GLP-1/GLP-2 therapy.

Please have the following information ready:

Personal information (name, contact details)
Medical history and conditions
Current medications and allergies
Insurance information (if applicable)

The form will take approximately 10-15 minutes to complete.

You can navigate between pages using the Next and Previous buttons.

Personal Information

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Address Information

Street Address *

City *

State *

ZIP Code *

Medical History

Current Medications

Please list all current medications you are taking *

Are you currently taking any weight loss medications? *

Please select all that apply:

Ozempic (Semaglutide) Wegovy (Semaglutide) Mounjaro (Tirzepatide) Saxenda (Liraglutide) Victoza (Liraglutide) Other None

Allergies

Do you have any medication allergies? *

Yes No

Weight & Health Goals

Current Weight (lbs) *

Height *

Goal Weight (lbs) *

What are your primary weight loss goals? *

Previous Weight Loss Experience

Have you tried any of the following weight loss methods? *

Please select all that apply:

Diet and Exercise Weight Loss Medication Weight Loss Surgery Medical Supervision Commercial Programs (Weight Watchers, Jenny Craig, etc.) None of the above

Please describe your experience with previous weight loss attempts

Lifestyle Information

How would you describe your current activity level? *

Please select the applicable option:

Sedentary (little or no exercise) Lightly Active (1-3 days/week) Moderately Active (3-5 days/week) Very Active (6-7 days/week) Extremely Active (physical job or training twice per day)

Do you smoke or use tobacco products? *

Yes No Former User

How often do you consume alcohol? *

Never Rarely (1-2 times per month) Occasionally (1-2 times per week) Regularly (3-4 times per week) Daily

Women's Health (If Applicable)

Are you currently pregnant or breastfeeding? *

Are you planning to become pregnant in the next 6 months? *

Yes No Not Applicable

Additional Information

Have you experienced any of the following conditions? *

Please select all that apply:

Pancreatitis Gallbladder Disease Multiple Endocrine Neoplasia (MEN) syndrome type 2 Personal or family history of Medullary Thyroid Cancer Gastroparesis (delayed stomach emptying) Depression or Anxiety Eating Disorder None of the above

Is there anything else you would like your provider to know?

Select Your Product

Choose your GLP-1/GLP-2 product *

Consent

I consent to receive GLP-1/GLP-2 medication as prescribed by a licensed provider

I understand the potential side effects and have been given the opportunity to ask questions

I authorize the provider to share my information with the pharmacy for fulfillment

I agree to automatic medication refills and recurring charges using my payment method on file. I understand I can cancel or modify auto-refills at any time before the next refill is processed.

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