FILL OUT THE FORM BELOW {"field_db22bca":{"display_mode":"show","fire_action":"All","file_types":"pdf, jiff, jpg, jpeg, png","logic_data":[{"cfef_logic_field_id":"field_6f40eff","cfef_logic_field_is":"==","cfef_logic_compare_value":"yes","_id":"7ad3ca9"}]},"field_181e753":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"drugallergy","cfef_logic_field_is":"==","cfef_logic_compare_value":"yes","_id":"b3c05bd"}]},"field_037f776":{"display_mode":"show","fire_action":"All","file_types":"png","logic_data":[{"cfef_logic_field_id":"Medications","cfef_logic_field_is":"==","cfef_logic_compare_value":"yes","_id":"29c17ca"}]}} First Name Last Name Email Phone Date of Birth Are you here to be evaluated for weight loss? Yes No Are you willing to reduce your caloric intake alongside medication? Yes No Are you willing to increase your physical activity alongside medication? Yes No Are you CURRENTLY taking any PRESCRIPTION medications for weight loss? None at this time Wegovy/Mounjaro/Ozempic/Trulicity/Saxenda Compounded Semaglutide Compounded Tirzepatide What is your goal weight in Pounds ? When was the last time you had an in person medical evaluation? Less than a year ago 1 to 2 years More than 2 years ago Have you had any lab tests completed within the last 6 months that you would like to share with your doctor? Yes No, not at this time Please Upload the most recent Lab tests if available. Do you have any of the following?(These are considered 'co-morbidities' by the American Board of Obesity Medicine. While you may not need to have one of these for treatment, your doctor would like to know.) High cholesterol Fatty Liver Disease High Blood Pressure Obstructive sleep apnea Pre-diabetes/Type 2 Diabetes/Hba1c above 5.7 History of medullary thyroid cancer Recent bariatric surgery or other Gl surgery(less than 6 months ago) History of MEN-2 (multiple endocrine neoplasia syndrome type 2) History of gallbladder disease (not including gallbladder removal/cholecystectomy) Liver disease/cirrhosis Leber Hereditary Optic Neuropathy (LHON) Anyone in your family With MEN2 (multiple endocrine neoplasia syndrome type 2) Anyone in your family with Medullary thyroid cancer Leber optic nerve atrophy Cyanocobalamin hypersensitivity (allergy) Benzyl Alcohol Allergy History of kidney failure Seen a kidney specialist in the past 12 months History of solitary kidney, or kidney transplant NONE of the above We require that you provide a recent blood pressure measurement within the last six months.(Blood pressure should be listed as follows: Systolic (top number) / Diastolic (bottom number)lf you are not sure, please go have your blood pressure obtained (often free at your local pharmacy).) Please read the following about all GLP-1s HOW THEY WORK: Increasing insulin production from the pancreas. Decreasing glucagon release after a meal. Glucagon triggers your liver to store fat. Slows gastric emptying, which will make you feel 'full'. BENEFITS: GLP-1's have been shown to help with weight reduction when combined with lifestyle medications such as exercise and reduction of caloric intake. RISKS: Medicines in the GLP family have caused thyroid tumors in lab mice. It is not yet known if they will cause thyroid tumors or medullary thyroid carcinoma (MTC) in people. No studies have confirmed a linkage between GLP-1's and thyroid tumors in humans. COMMON SIDE EFFECTS: Nausea, constipation, gastrosophageal reflux, diarrhea, fatigue. YOU SHOULD NOT USE A GLP-1 IF YOU HAVE ANY OF THE FOLLOWING: Eating Disorder Gallbladder Disease (does not include gallbladder removal/cholecystectomy) Severe Gl disease (eg: gastroparesis, Crohns, ulcerative colitis) Drug Abuse Alcohol Abuse Recent Bariatric Surgery Chronic pancreatitis, or pancreatitis while taking a GLP-1 Personal or familv historv of medullary Thvroid Cancer Multiple endocrine neoplasia type 2 syndrome (MEN-2) Currently Pregnant (or planning to become pregnant) Currently Breastfeeding Retinopathy Do you consent to being treated with GLP-1 agonists ? YES, I CONSENT to being treated with GLP-1 agonists. I have reviewed the risks and benefits above. NO, I DO NOT consent to being treated with a GLP-1 Please provide a current, FULL body photo of yourself wearing form fitting clothing holding up your drivers license.*This is a requirement for weight loss therapy.*We take your privacy seriously. ID Verification: We'll need a clear picture of a valid ID or drivers license so we can verify the personal data you provided is accurate. Do you have any drug allergies? Yes - Please list your allergies and any known reaction No - I affirm I have no known drug allergies Are you taking any medications? Yes - Please list names and doses. No - I am not taking any medications. Let's get your numbers. Height (feet). Height (inches). Weight (lb). How did you hear about us? Groupon Google search Friend Other Submit CONTACT US Do you have questions? Contact Us and we will help you! Email: Support@LeanerRx.com
