Medically Directed Weight-loss
Semaglutide | Tirzepatide
Date of Exam:
-
Month
-
Day
Year
Date
Client Name:
First Name
Last Name
Client Date of Birth:
-
Month
-
Day
Year
Date
Allergies:
Past Medical History | Surgeries:
Current Health Concerns:
Please provide information about any medications you are currently taking, including prescription medications, vitamins, supplements, and over-the-counter medications:
Are you pregnant?
Yes
No
Last pregnancy?
Are you breastfeeing?
Yes
No
Current Weight:
Goal Weight:
Desired Timeframe:
Physician Comments / Notes:
The client satisfies the requirements for receiving weight loss injections:
Please Select
Yes
No
Approved Weight Loss Injections:
Semagluitde
Tirzepatide
Physician Signature
Continue
Should be Empty: