Wellness Intake Form

Tell Us a Bit About Yourself – Required for Prescriptions
Full Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
How would you prefer to be contacted?*

CallEmailText
Select only if applicable.*

I have a personal or family history of thyroid cancer (including medullary thyroid carcinoma or MEN2).I have a history of pancreatitis.I am currently pregnant, planning to become pregnant, or breastfeeding.I have been diagnosed with any type of cancer (past or present).I have severe gastrointestinal disease (such as gastroparesis).I have kidney or liver disease.None of the above apply to me.
Do you have any known allergies to medications or ingredients?*

YesNo
If you answered yes to the above question, please list below.
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Tell Us a Bit About Yourself – Required for Prescriptions