Medallus ND GLP-1 Patient Assessment-Consent Form

GLP-1 Medication Patient Assessment

SEMAGLUTIDE - TIRZEPATIDE - SERMORELIN
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
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.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
How did you here about this program?

Social MediaA FreindMy PCPMy EmployerOther

Weight Loss Information
Weight Loss Information
Your Current Weight
CLICK HERE TO CALCULATE YOUR BMI
BMI Less than 27?

YESNO
Registered Dietician Services (optional)

If you are interested in Nutritional and Lifestyle Counseling and your employer is contracted with Medallus Medical (i.e., NDPHIT, JPS, WFPS, MPS, DPS, GFPS) click HERE to schedule with a Registered Dietician. This service could be covered at 100% and in addition to GLP-1 services.

If you are interested in Nutritional and Lifestyle Counseling and your employer is not contracted with Medallus Medical, please discuss your interest in this service with your provider at the consultation.

Health Insurance Information
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?

YesNo
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
GLP-1/Peptide Information
Are you a first time user of GLP-1 Medications?

YESNO
Are you currently taking any GLP-1 medications?

YESNO
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?

YESNo
What other medication or supplements do you currently take?

Glucose Lab Test
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?

YESNO
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