Ozempic/Wegovy/ Zepbound/Mounjaro

CONGRATULATIONS ! Your Weight loss journey starts HERE !

Congratulations! Your weight loss journey starts HERE! Medications we offer: Semaglutide (Ozempic/Wegovy) and Tirzepatide (Zepbound/Mounjaro)
Name*

First NameLast Name
Gender*

MaleFemaleNon Binary
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Height *
Weight in pounds (lb):*
Email *
example@example.com
Are you in good health at the present time?*

YESNO
Are you under a physicians care at the present time?*

YESNO
Any allergies? Drug allergies?*

NOOther
Are you taking any medications at the present time? Other medications for weight loss?*
Have you had any:*

SurgeriesSerious InjuriesNone
ONLY fill this out if you answered yes to surgeries or serious accidents.
Family history of (must answer):*

NoneGlaucomaAsthmaEpilepsyHigh Blood PressureKidney DiseaseDiabetesTuberculosisPsychiatric DisorderHeart Disease / StrokeOther
If you have any of the below please check off:*

NoneHistory of High Blood pressureHeart DiseaseDiabetesHeart attack or Chest painSwelling FeetFrequent Headaches / MigrainesConstipationGlaucomaHormone replacement therapyBirth Control
Do you have a FAMILY history of cancer? Thyroid cancer?*

YesNo
Have YOU had a history of cancer?*

YesNo
Have YOU had a person history of Thyroid Cancer?*

YesNo
Are you pregnant or breastfeeding ?

YesNo
Have you had pancreatitis or a history of pancreatic issues?*

YesNo
Do you have a history of cardiovascular diseases (e.g., heart attack, stroke)?*

YesNo
Have you ever had bariatric surgery?*

YesNo
If you had any of the following please write below: Measles, Mumps, Scarlet Fever, Whooping Cough, Bleeding Disorder, Gout, Heart Valve Disorder, Gallbladder Disorder, Eating Disorder, Malaria, Cancer, Osteoporosis, Polio, Jaundice, Kidneys, Lung Disease, Rheumatic Fever, Ulcers, Anemia, Tuberculosis, Drug Abuse, Pneumonia, Cholera, Arthritis, Tonsillitis, Pleurisy, Liver Disease, Chicken Pox, Nervous Breakdown, Thyroid Disease, Heart Disease, Psychiatric Illness, Alcohol Abuse, Typhoid Fever, Blood Transfusion, or anything else? (Write below)
Calculate your BMI for next question:
Enter your BMI below ( BMI < 18.5 = Underweight , BMI 18.5 to 24.9 = Healthy Weight, BMI 25.0 to 29.9 Overweight, BMI 30.0 or higher Obese)
Reason for weight gain & goal weight to lose?*
Have you ever undergone a Right Upper Quadrant (RUQ) sonogram? *Gallbladder*
Have you tried dieting before? What have you done?*
When did you begin gaining excess weight? (Give reasons, if known):*
What has been your maximum lifetime weight (non-pregnant) and when?*
How often do you eat out?*
Any specific time of the day or month do you crave food?*
Do you drink alcohol? Soda? Coffee?*
What are your worst food habits? *
Do you smoke? How much?*
What do you eat for breakfast? Lunch? Dinner?*
How often do you exercise?*

0x a week1x a week2x a week3x a week4x a weekI walk a mile a day
Which medication were you looking to start?*

OzempicWegovyMounjaroZepboundOther
How did you hear about us?*

GoogleFacebookWord of mouthFlyer
Please describe your general health goals and improvements you wish to make:*
You can find more Information from manufacturer directly, please click and read the link below based on the medication you will be starting:

Wegovy Package Insert Link

Ozempic Package Insert Link

Zepbound Package Insert Link

Mounjaro Package Insert Link
GLP-1 medications, like Ozempic, Wegovy, and generic Semaglutide, mimic the GLP-1 hormone to help control blood sugar, slow digestion, and reduce appetite, leading to weight loss. GIP medications enhance the insulin response to high glucose levels. Tirzepatide (Mounjaro) and Zepbound are newer treatments that combine the effects of both GLP-1 and GIP hormones to provide comprehensive blood sugar control and promote weight loss. These medications are typically administered as weekly injections.
Please read and acknowledge everything below. *** You will need to acknowledge all 8 below***

Any questions / concerns you may ask us before signing.
**Acknowledgment and Informed Consent**I, the undersigned, hereby affirm that I have carefully reviewed and fully understand the information provided in the preceding documents. I acknowledge that I have been informed in detail about the nature of the proposed treatment, including but not limited to, the expected benefits, potential risks, side effects, and any alternative treatments available.I have been given ample opportunity to ask questions regarding the treatment and have received satisfactory answers to all inquiries. My decision to proceed with the treatment is made freely, without duress, and based on a balanced understanding of its potential outcomes.I recognize that the practice of medicine and surgery is not an exact science, and I acknowledge that no guarantees have been made to me as to the results of the treatment or any procedures undertaken.By signing below, I express my consent to proceed with the proposed treatment plan. I release IVS FOR ME LLC, its healthcare providers, staff, and affiliates from any liability for all outcomes directly or indirectly associated with the treatment, to the fullest extent permitted by law.I understand that this consent is voluntary and that I may withdraw my consent at any time prior to receiving treatment without affecting my future care or treatment relationship with IVS FOR ME LLC. **

Powered by Jotform SignClear
PHOTO ID *DRIVER'S LICENSE REQUIRED**

Cancelof
LABS (please upload recent labs IF you have them)

Cancelof
Should be Empty:

CONGRATULATIONS ! Your Weight loss journey starts HERE !

Please read and acknowledge everything below. *** You will need to acknowledge all 8 below***

Please read and acknowledge everything below. * You will need to acknowledge all 8 below*