Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Mobile phone number
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Please enter a valid phone number.
Physician's Name
*
Physician's Phone Number
*
Please enter a valid phone number.
Date of Birth
*
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Month
-
Day
Year
Date
Age
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Height
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Weight
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Are you taking: Semaglutide or any other GLP-1 agonist Such as: Adlyxin®, Byetta®, Bydureon®, Ozempic®, Rybelsus®, Trulicity®, Victoza®, Wegovy®; Insulin and Sulfonylureas (e.g., g lyburide, glipizide, gl imepiride, tolbutamide) due to the increased risk of hypoglycemia (low blood sugar).
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Yes
No
Do you have any allergies?
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Yes
No
Are you taking medications?
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Yes
No
Medical History
*This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details. Before using this medication, tell your doctor/pharmacist your medical history.
Please check all that apply:
Do you or a family member have a history of medullary thyroid carcinoma (Thyroid Cancer)?
Multiple endocrine neoplasia syndrome type 2
Are you diabetic and/or taking any medications related to lowering your blood sugar levels without speaking with your endocrinologist?
Are you prescribed insulin? (The combination may increase your risk of hypoglycemia (low blood sugar) and dosage adjustments by your provider may be necessary)
Do you have a history of pancreatitis?
List and/or Explain Other Medical Conditions not listed above:
Previous Hospitalizations / Operations:
Are you pregnant and/or breastfeeding?
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Pregnant
Breastfeeding
Neither
What are your weight loss goals?
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Disclaimer
*
I understand the information on this form is essential to determine my medical needs & the provision of treatment. I understand that if any changes occur in my medical history/health I will report it to the office as soon as possible. I have read and understand the above medical history questionnaire. I acknowledge that all answers have been recorded truthfully and will not hold any staff member responsible for any errors or omissions that I have made in the completion of this form. I consent to the use of semaglutide/non-surgical weight loss injections and understand that the medication is compounded. The most common side effects include nausea, GI upset and constipation.
Service Date
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Month
-
Day
Year
Date
Signature
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