Thina Meds Semaglutide Subscription Health Form

Semaglutide Health Form

Thina Meds Weight Loss Programs
Full Name*

First NameLast Name
What is your age?*
What is your gender?*
What is your Phone Number*
Format: (000) 000-0000.
Email Address*

Confirmation EmailConfirm your email
What is your Date of Birth?*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

How tall are you?*
What is your height?
How much do you Weigh?*
Provide your weight
What is your desired Weight?*
Provide your desired weight
Other Physicians Testing You*
Please type none if not applicable
Hospitalizations or Surgeries within the last 3 years*
Please type None if not applicable
YesNoN/A
YesNoN/A
YesNoN/A
FEMALES ONLY No. of Live Births
How many live Births have you had?
FEMALES ONLY Miscarriages
Have you had any Miscarriages and if so how many?

YesNo
If you or anyone in your family been diagnosed with LEBER'S DISEASE (B12 Allergy), Whom?
Please answer if any family member had been diagnosed with LEBER'S DISEASE (B12 Allergy)
YesNo
YesNo
YesNo
We require that you provide a recent blood pressure measurement within the last six(6) months.*
Blood pressure should be listed as follows: systolic (top number) / Diastolic (bottom number). If you are not sure, please go have your blood pressure obtained (often free at your local pharmacy).
Name of Persons we may inform regarding your medical information:

Please Enter Name/Phone Number of the the Persons whom we could contact.
Provide Name & Phone Number (1)*
Provide Name & Phone Number (2)*

Thank You For Applying To Our Program

Notice Regarding Your Application

Thank you for applying to our weight loss program. We appreciate your interest and the time you’ve taken to complete the application.

After reviewing your responses, we regret to inform you that, based on the medical information provided, we are currently unable to process your prescription. This decision is based on specific criteria to ensure the safety and suitability of the treatment for all participants.

We understand that this news may be disappointing. Please be assured that this precautionary measure is in place to ensure the best possible outcomes for all patients.

If a credit card charge was made, we will issue a full refund promptly. If you have any questions or need assistance with other services, please feel free to contact us at 407-624-5258.

Thank you for your understanding.

Best regards,

Thina Meds

Please Provide a Full Body Photo*

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Patient Driver's License or State Issued ID #*
Enter your Driver License ID #
Patient Driver's License # or State issued ID*

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This is a monthly subscription for Semaglutide, designed to support your ongoing weight loss journey. You have the flexibility to cancel your subscription at any time with a 30-day notice.*

Semaglutide 2.5mg/ml (2ml Vial)($199.00 for the first payment then,$299.00 for each month)

Enhance your weight management journey with Semaglutide in a 2.5mg/ml concentration, conveniently provided in a 2ml vial. Semaglutide is an effective prescription medication aimed at supporting weight loss and helping you achieve your health goals. Product Details: Strength: 2.5mg/ml Volume: 2ml vial Form: Injectable solution This smaller vial is ideal for those seeking a short-term supply or a trial period to assess the effectiveness of Semaglutide. It’s designed to mimic a natural hormone that helps regulate appetite and facilitate weight loss under professional supervision. Shipping Information: Delivery: Fast and secure shipping to ensure timely receipt of your Semaglutide. Packaging: Discreet and secure packaging to maintain privacy and medication quality. Handling: Proper handling procedures to keep the medication in optimal condition during transit.

Semaglutide 2.5mg/ml (5ml Vial)($549.00 for the first payment then,$649.00 for each month)

Achieve your weight management goals with Semaglutide in a 2.5mg/ml concentration, now available in a 5ml vial. This larger vial provides an extended supply, ideal for continuous treatment and long-term use. Product Details: Strength: 2.5mg/ml Volume: 5ml vial Form: Injectable solution The 5ml vial is designed for ongoing use, offering a more extended supply of Semaglutide. It’s formulated to mimic a natural appetite-regulating hormone, supporting weight loss and overall health improvements when used as directed by your healthcare provider. Shipping Information: Delivery: Reliable and prompt shipping to ensure your Semaglutide arrives quickly. Packaging: Secure and discreet packaging to protect the medication and ensure privacy. Handling: Strict adherence to handling guidelines to maintain medication quality during delivery.

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PATIENT RELEASE ACKNOWLEDGEMENT:

1. By reviewing my medical information, the physician will decide if medication will help in my weight loss goals. I understand that it is my responsibility to continue with my regular physical exams with my family physician. If any charges occur in my physical health that could affect my weight loss, I will immediately notify ThinaMeds.com or AcuMedGroup LLC. I agree that should I suffer any adverse reactions while taking ANY prescription medication, I will stop the medication and contact my physician.

2. I understand and agree that the physician is only reviewing my medical information as I have related to HER or HIM and the staff. I understand and agree that I have informed ThinaMeds.com or AcuMedGroup LLC. of any medical conditions. I understand that the physician is only approving or denying me for this weight loss program.

3. I understand and agree that the review of my medical information by ThinaMeds.com or AcuMedGroup LLC. is not intended to diagnose any medical condition and I will continue to see and get advice from my primary physician.

4. Should I have any concerns about the weight loss program, I will contact my primary doctor before taking any medications.

5. I confirm that I am 18 years of age or older and that I am fully competent to make my own decisions concerning my healthcare. I am fully aware as with all medications, there are risks for side effects. I understand and agree that it is a violation of law to falsify information about my medical records and questionnaires to obtain prescription medication. If I fail to provide accurate medical information including, current and past medical conditions, I understand and agree that I am solely responsible for any adverse effects that I may have from taking such prescription medication.

6. I agree that ThinaMeds.com or AcuMedGroup LLC. and its employees will not be held responsible for any liability, claim, loss, damage, or any other expense incurred by the prescribed approved medication.

7. I have read and understand all the above-referenced patient acknowledgments, and agree to each of the terms.

8. I understand that all prescription medication is not returnable and not refundable.

9. PEOPLE TAKING SEMAGLUTIDE FOR WEIGHT LOSS MAY EXPERIENCE: Dizziness, Fatigue, Gastrointestinal issues, such as diarrhea, constipation, and gassiness, Headache, and Stomach issues, including nausea, vomiting, pain, or distention (bloat).
Patient Signature*

Semaglutide Health Form

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