Dr. Jatoi Medical Weight Loss Intake Form

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Patient Name* This field is required.
First Name
Last Name
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Patient Information* This field is required.
Date of Birth
Cell Phone Number
Please enter your email
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Patient Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Dr. Jatoi Medical Weight Loss Introduction VideoGoes over my medical weight loss program.
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Weight Questions* This field is required.
Current Weight
Goal Weight
Height
Please Select
Please Select
Semaglutide
Tirzepatide
I'm unsure - need consultation
Preference of Weight Loss Medication
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Medical History Questions* This field is required.Do you or any of your family members have a history of MEN Syndrome Type II or medullary thyroid cancer?
YESNO
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Diabetes Mellitus Questions* This field is required.
Please Select
Please Select
Yes
No
Are you a Type I Diabetic?
Please Select
Please Select
Yes
No
Do you take Insulin, Glyburide, or Glipizide?
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Hvae you previously been on any of the following for weight loss in the past?* This field is required.
Semaglutide
Tirzepatide
Phentermine
Structured Exercise Programs
Contrave
HCG
Keto / Other Diets
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Are you currently on GLP1s?* This field is required.
YESNO
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How many mg of Semaglutide or Tirzepatide are you on?NOT UNITS -- CONVERT TO MG PLEASE
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Preference of Medication* This field is required.
Semaglutide
Tirzepatide
Need Consultation (unsure)
Other
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Comments / Concerns / Questions (optional)Any additional comments, concerns, questions that you may have for Dr. Jatoi that is pertinent to medical weight loss journey in the past or now? Feel free to attach any pertinent attachments, labs, records you feel is appropriate. Labs are not necessary to start on GLP-1 treatment, but may will be required if you want metformin to augment weight loss with GLP-1 injectables.
Huge
Large
Normal
Small
Ok
Ok
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Physician Fees - Medical Weight Loss Concierge Fees* This field is required.This fee provides direct access to Dr. Mansoor Jatoi for advice on dose adjustments, questions about medications, side effects, and dose changes. It is required for ordering new prescription GLP-1 medications. New Patient Medical Weight Loss Concierge/Doctor Fees: $185 (covers the first two months of services for new patients). After the first two months, the membership will automatically renew at $120 every two months using the credit card on file, unless canceled in advance. If you cancel or let your concierge membership lapse and wish to re-enroll, there is a $50 re-enrollment fee. Cost of medication is in addition to above fees. A patient can't re-order medications unless on service. The medical weight loss concierge fees ONLY cover health services specific to weight loss, also including side effects related to weight loss including but not limited to: nausea, heartburn, and hair loss.
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Terms and Conditions* This field is required.SEMAGLUTIDE DOSING: Weeks 1-4: dose 0.25mg weekly Every 4 weeks dose can be adjusted up based on the dosing scale shown below Semaglutide 0.25mg, 0.5mg, 1mg, 1.7mg, 2.5mg Some stay on lower doses longer if appetite is suppressed VIAL OPTION #1 - 2.5mg vial $150 if new start on medication you will get 7 weeks/doses of medication on this vial 0.25mg for 4 weeks (1mg total), then 0.5mg for 3 weeks (1.5mg total) first 7 weeks in vial VIAL OPTION #2 - 5mg vial $200 if new start on medication you will get 10 weeks/doses of medication on this vial 0.25mg for 4 weeks (1mg total), then 0.5mg for 4 weeks (1.5mg total), then 1mg weekly for 2 weeks Larger Vial is available for patients transitioning from another provider/services. -------------------------------------------------------------------------------------------------------------------------------- TIRZEPATIDE DOSING: Weeks 1-4: dose 2.5mg weekly Every 4 weeks can go up by 2.5mg Tirzepatide 2.5mg, 5mg, 7.5mg, 10mg, 12.5mg, 15mg VIAL OPTION #1 - 33.2mg vial - $320 add up your weekly doses and divide by the vial mg to see how many doses you get If a new start this vial will get you 8 weeks of medication 2.5mg for 4 weeks (10mg total) then 5mg for 4 weeks (20mg total) VIAL OPTION #2 - 74.7mg vial - $505 These vials aren't recommended to be used beyond 12 weeks This is the option if you are on Tirzepatide 7.5mg or higher typically -------------------------------------------------------------------------------------------------------------------------------- Upon consultation, a custom-tailored medication weight loss plan will be provided with options being provided to you on deciding how you want to proceed. If you don't want to proceed with the weight loss options presented your initial consultation fee is completely refundable if you decide not to continue on our concierge weight loss program.
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How did you hear about my services?* This field is required.
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Signature of Consent and AgreementBy providing your mobile number, you consent to receive text messages from Dr. Jatoi Direct Primary Care to discuss your healthcare-related information, test results, and appointments. Text messages may include sensitive health information. Standard messaging rates may apply. If you decide to sign up, you agree to a medical weight loss concierge membership that automatically renews every two months. The cost is $120 every two months unless you cancel beforehand, medication costs are separate. By signing below you are agreeing to start the medical weight loss program, if accepted, and ready for consultation and payment. Privacy Policy can be reviewed by Clicking here. After consultation if you wish to not proceed your concierge services fee is completely refundable if asked for at the end of the initial consultation visit. If you do not wish to start, please close out of this window. Email questions you may have to Dr. Jatoi - mjatoi@drjatoidirectprimarycare.com AFTER YOU SIGN THIS FORM YOU WILL BE TAKEN FOR PAYMENT THAT WILL ALLOW US TO SCHEDULE YOUR CONSULTATION -- THIS IS REQUIRED TO SETUP A CONSULTATION.
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