Weight Loss Pre-Screen

Full Name*

First NameLast Name

E-mail Address*

example@example.com

Contact Number*

Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code

Date of Birth*

DayMonthYear

Has your doctor ever said your blood pressure was too high or too low?*

YesNo

Please provide details.

Do you have a history of thyroid cancer or MEN Multiple Endocrine Neoplasm or any type of cancer or a family history of cancer?*

YesNo

Please provide details.

Do you have any known cardiovascular problems (abnormal ECG, previous heart attack, etc)?*

YesNo

Please provide details.

Has your doctor ever told you that your cholesterol was too high?*

YesNo

Please provide details.

Have you (or a family member) ever been told that you have diabetes?*

YesNo

Please provide details.

Are you taking any prescribed medications or dietary supplementation?*

YesNo

Please provide details.

Do you ever have problems sleeping?

YesNo

Are you pregnant or post-partum ( Less than 6 weeks)?*

YesNo

Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise/activity?*

YesNo

Please provide details.

Have you ever been diagnosed with any of the following?*

Provide additional information on any of conditions listed above. If none, enter N/A*

Do you have any other medical condition, injury or anything else we should be aware of that you have not mentioned?*

YesNo

Please provide details. Enter N/A if no additional information.*

When was your last physical with labs?*

Date

List all drug allergies below. Write N/A if you do not have any allergies*

What is Your Height?*

What is Your Current Weight?*

What is Your Target Weight?*

Why do you want to achieve your target weight? Please be detailed.

Who else does this goal affect?

Spouse / PartnerChild(ren)Career / BusinessOther

How long has this been your goal?

Are you ready for a change and need help?

YesNoOther

What have tried in the past to lose weight? Please list all programs or diets starting with the most recent.

If accepted into our program, will you take the prescribed medications and follow all recommended protocols and advice given to ensure your desired results?*

YesNoOther

Please Provide Your Preferred Pharmacy Phone Number

Please enter a valid phone number.

Please provide your preferred Pharmacy Name and Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Upload a copy of a valid identification like a Driver's License, Passport, or State ID.*

Medication Policy:

We want to bring to your attention an essential policy regarding medication orders. Once an order for medication has been placed and processed, we regret to inform you that refunds will not be provided. This policy is in place to ensure the safety and quality of pharmaceutical products and to comply with regulatory guidelines. We understand that circumstances may arise where a change or cancellation is needed. Still, due to the nature of our industry and the importance of maintaining the integrity of medications, we cannot offer refunds once the order has been finalized. We encourage you to carefully consider your prescription needs before placing an order. Our dedicated team is here to assist you in any way we can to ensure your satisfaction and optimal healthcare experience. Thank you for your understanding and continued trust in our services.

Dr. Tola T’Sarumi, MD, LLC

PLEASE READ THE BELOW INFORMATION CAREFULLY AND CONSENT:

Human-based glucagon-like peptide-1 receptor agonists (GLP-1 RA) such as Semaglutude (compounded), Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® are prescribed as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) that is considered outside a healthy range.

Do not take this medication if:

You have a personal or family history of medullary thyroid carcinoma (Thyroid Cancer)
You have a personal history Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
You are pregnant or plan to become pregnant while taking this medicine.
You are diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist or primary care provider. Specifically, if you are prescribed Insulin because the combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary.
You are allergic to Semaglutide or any other GLP-1 agonist such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Mounjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST)

Possible drug interactions:

Anti-diabetic agents, specifically insulin and sulfonylureas (e.g., glyburide, glipizide, glimepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar). Do not take with other GLP-1 agonist medicines such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy® Maunjaro® (THIS IS NOT AN ALL-INCLUSIVE LIST). Disclose all medications you are on

Possible side effects:

Nausea, diarrhea, vomiting, constipation, abdominal pain, headache, fatigue, dyspepsia, dizziness, abdominal distension, belching, hypoglycemia, flatulence, gastroenteritis, and gastroesophageal reflux disease.

Possible side effects of subcutaneous injections:

Itching and burning at the site of administration with or without thickening of the skin

If notice other side effects not listed above, contact your healthcare provider. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, or trouble breathing. Report adverse side effects to your clinician. In the event of any emergency, call 911 immediately.

Tirzepatide/Semaglutide protocol:

Every 30 days, you must request a refill and self-report: your current weight, blood pressure, concerns regarding treatment, change in other prescribed medications, change in medical history, and change in desired weight loss outcome.
It can take 14-20 business days to receive some forms of semaglutide. Please be mindful of self-reporting in a timely manner to not delay your administration.
We do offer office visits and assistance. Please notify our office immediately of any concerns or questions you have: 1-(844) 777-9246.
In the event of an emergency, call 911 immediately.

IF YOU HAVE ANY QUESTIONS AS TO THE RISKS OR HAZARDS OF THIS TREATMENT, OR ANY QUESTIONS CONCERNING THIS PROPOSED TREATMENT OR OTHER POSSIBLE TREATMENTS, ASK NOW BEFORE SIGNING THIS CONSENT FORM.

By signing, I certify that I have read and understand the contents of this form. I am aware of the possible side effects and drug interactions and give my consent for treatment. I have informed the medical staff of any known allergies to drugs or other substances and any past adverse reactions I’ve experienced. I have informed the medical staff of all medications and supplements I’m currently taking. I understand there are other ways and programs that can assist me in my desire to decrease my body weight, and acknowledge that no guarantees have been made to me concerning my results.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS:

I agree to release Dr. Tola T'Sarumi and all her associates from all medical liability and malpractice claims related to any and all care.

This consent covers the initial and all future prescriptions for this medication. I understand this is prescription therapy and is not eligible for a refund or reimbursement.

I have read and agree with the above. My questions have been answered and I understand the treatment and goals. I understand and accept the potential risks associated with GLP-1 RA therapy as stated above and consent to treatment.

I agree to release Dr. Tola T'Sarumi and all her associates from all medical liability and malpractice claims related to any and all care.

I have read through all the above information and if I have questions, I will ask the doctor.

I certify that I have been informed of the risks and benefits of off-label treatment.

I agree to have Dr. Tola T’Sarumi, MD LLC charge my card for medication.

I will review the side effects of all medications I am prescribed and immediately inform the doctor of any side effects. I acknowledge and agree that I have read the Medical Disclaimer above, and I am authorizing Dr. T’Sarumi to proceed with our telemedicine visit.

E-Signature (by typing out your full name, you are confirming that you have reviewed the consent form and provided the correct information to be used as part of your assessment for acceptance into our weight loss program).*

Clear

Date*

Date

Please verify that you are human*