Medallus ND GLP-1 Patient Assessment-Consent Form

GLP-1 Medication Patient Assessment
No Cost Assessment for GLP-1 Medication for Weight Loss Program Participants

Complete this 5-minute GLP-1 assessment form and begin your weight loss today!
- Demographic Information
- Name
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Sex
- Gender Idenity
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Date of Birth
  
  MonthDayYear
  Date
- How did you here about this program?
- Primary Care Provider Information
- Primary Care Physician (PCP) Name
- Primary Care Physican (PCP) Telephone Number
- Weight Loss Information
- Your Current Weight
- CLICK HERE TO CALCULATE YOUR BMI
- BMI Less than 27?
- Health Insurance Information
- If applicable, to assist with 100% insurance coverage on Nutrition and Lifestyle Counseling, what is your current Primary Insurance carrier?
  e.g., Blue Cross and Blue Shield
- Upload Insurance Card
  
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- Subscriber Name (if different than yourself)
- Subscriber's Date of Birth (if different than yourself)
- Subscriber's relationship to you?
  e.g., self, spouse, child, grandparent
- If you have health insurance through an Employer plan, who is the Employer?
- NDPHIT Members Only: Are you a non-diabetic, starting a GLP-1 program for the first time (after July 1, 2024), and referred by Digbi Health?
- NDPHIT Members Only: If "No" was selected to the above question, please contact Digbi Health to obtain the pre-authorization required to begin the GLP-1 process.
- GLP-1/Peptide Information
- Are you a first time user of GLP-1 Medications?
- Are you currently taking any GLP-1 medications?
- If applicable, what is the current GLP-1 medication that you are taking?
  e.g., semaglutide
- If applicable, what is the current weekly GLP-1 medication dosage of prescription?
  e.g., .25mg
- Do you have a known allergies to Semaglutide or Tirzepatide or any GLP-1 agonists?
- What other medication or supplements do you currently take?
- Medical History
- Personal or familial history of Medullary Thyroid Carcinoma (MTC)?
- Do you have multiple Endocrine Neoplasia Type 2?
- Do you have a medical diagnosis of DIABETES TYPE 1 or TYPE 2? (If yes, a medical document will need to be provided to confirm diagnoses i.e., letter from provider, a screen shot of medical records etc.)
- File Upload of Diabetes Verification*
  
  *The verification can also be faxed 701-540-6818, emailed or submitted in person
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- This is a medication weight management program and does not replace and should not contradict the treatment or advice of your treating provider. It is highly recommended that you continue the care of your current primary care phyisician (PCP) who can ensure the monitoring of your health or any other medications. If you're taking medications, especially for diabetes, high blood pressure or hypothyroidism, they will require ongoing monitoring as your needs may change during and after the program.
- Do you have Pancreatitis?
- Do you have an active Gallbladder Disease?
- Do you have any Kidney Disease that is stage 2 or higher?
- Do you have symptoms of Gastroparesis?
- Do you have chronic or persistent Hypoglycemia with abnormal ranges?
- Personal concerns with or history of (select all that apply):
- Are you currently pregnant?
- Are you currently breast feeding?
- Are you younger than 18 years of age?
- Glucose Lab Test
- GLP-1 Medication first time users are required to have a Glucose Blood Test.
  
  A Glucose Blood test can be completed in one of three ways:
  
  1 - Glucose Home Test Kit (see below)
  
  2 - Conducted in a Medallus Medical clinic
  
  3 - Provide your Glucose Blood lab results (see below)
  
  Your results will be reviewed and documented before ordering your GLP-1 medication.
- Glucose Home Test Kit
  
  Click Here to order your glucose home test kit if this is your first time assessment for GLP-1 medications.
  
  Your home test kit will be ordered and sent to the address you provide in this form within 5 to 7 business days and your results will be sent to you and the attending provider in a secured email within 5 to 7 business days from the time that the blood tests are received in the lab.
  
  Please follow the finger stick blood instructions carefully or it could provide unverfiable blood results.
- If you are a first time GLP-1 medication user, you acknowledge and consent that a Glucose blood test must be completed or provided with documented Glucose Blood lab results conducted within the past 60 days, and that your Glucose lab results are required before obtaining your first GLP-1 medication order?
- If you have had a recent Glucose blood test, please attach the results along with the date of test.
- File upload of a picture or lab test file of your most recent Glucose Blood test results
  
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GLP-1 Medication Patient Assessment

No Cost Assessment for GLP-1 Medication for Weight Loss Program Participants

Demographic Information

Primary Care Provider Information

Weight Loss Information

Health Insurance Information

GLP-1/Peptide Information

Medical History

Glucose Lab Test

GLP-1 Medication first time users are required to have a Glucose Blood Test.

Your results will be reviewed and documented before ordering your GLP-1 medication.

Consent