Patient Registration
Compound Medication Form
Full Name
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First Name
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Format: (000) 000-0000.
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Tell us about your medical history:
Include medication allergies, current medications, surgical history. You may include any significant labs or medical records in the next section.
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Tell us about your health and wellness goals:
GLP medications, including compound formulations, may cause tumors in the thyroid, including thyroid cancer. Have you, or any member of your family, ever been diagnosed with any of the following? Thyroid Cancer.Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).Medullary Thyroid Cancer (MTC).
*
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Which compound formulation are you seeking?
Semaglutide
Tirzepatide
Lipo B MIB
Lipo C
B12
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