FILL OUT THE FORM BELOW - ONLY FOR TIRZEPATIDE AND SEMAGLUTIDE PATIENTS.

First Name

Last Name

Phone

Date of Birth

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Yes I am aware No I decline

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.

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 Thyroid 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).

Are you pregnant?
Yes No N/A

You must notify us if you get Pregnant.
Yes, I am aware. No N/A

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LeanerRx

LeanerRX

FILL OUT THE FORM BELOW - ONLY FOR TIRZEPATIDE AND SEMAGLUTIDE PATIENTS.

We require that you provide a recent blood pressure measurement within the last six months.