New Patient Medical Weight Loss GLP1 Intake Form

New Patient Medical Weight Loss GLP1 Intake Form

805 1/2 w. Lake Bardwell Dr. Ennis TX 75119
Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PATIENT LOCATION & VISIT TYPE
TexasOklahomaFloridaWashingtonIowaColoradoVermontVirginiaConnecticutTennessee
In‑Person Visit (Texas patients only)Virtual / Telehealth Visit
⚠️ Telehealth services are only provided to patients physically located in one of our currrently licensed states at the time of the visit. Testosterone Replacement Therapy is limited to Texas in-person visit patients only.
Medical History
Type 1 DiabetesType 2 DiabetesThyroid Disease (Hypothyroidism/Hyperthyroidism)Personal or family history of Medullary Thyroid Cancer (MTC)Personal or family history of Multiple Endocrine Neoplasia syndrome type 2 (MEN2)PancreatitisGallbladder DiseaseKidney DiseaseLiver DiseaseGastroparesis or Severe GI Motility DisorderCardiovascular Disease (Heart Attack, Stroke, High Blood Pressure)History of Eating Disorders (Anorexia, Bulimia)Depression or AnxietyNone
I understand and acknowledge that GLP-1 medications are contraindicated in individuals with a current or prior diagnosis of medullary thyroid carcinoma (MTC), Multiple Endocrine Neoplasia syndrome type 2 (MEN-2), active pancreatitis, or severe gastroparesis. I understand that if I answer “Yes” to any of these conditions, I may not be eligible for GLP-1 therapy and treatment may be withheld or discontinued for medical safety reasons.*

YesNo
YesNo
If yes, please list all current medications & supplements (Please list all)
YesNo
If yes, please list all known allergies.
YesNo
If yes, which one have you tried in the past, when was your last dose, and what was your dose at the time?
Insurance denied coverage for brand-name GLP-1Brand-name medication cost was not affordable out-of-pocketBrand-name medication was unavailable or on backorderUnable to tolerate standard dose escalation with brand medicationRequired slower titration or micro-dosing not supported by brand medicationExperienced significant side effects with brand-name medicationPrior brand-name GLP-1 was discontinued by previous providerLost access due to insurance, pharmacy, or coverage changesAllergy or sensitivity to inactive ingredients in brand medicationTransitioning from brand-name to compounded for continuity of careOther (please explain)
If "other", please explain:
YesNo
YesNo
If yes, please list.
YesNo
Lifestyle & Weight Management Goals
What is your current weight? ___________ lbs*
What is your height? ___________ ft _____ in*
What is your goal weight? ___________ lbs*
Weight lossBlood sugar controlAppetite suppressionOther
If other, please list.
None1-2 times3-4 times5+ times
No specific dietLow carb/KetoMediterranean dietIntermittent fastingOther
NoYes, occasionallyYes, frequently
NoYes
NoYes
Additional Screening
Gastric SleeveGastric BypassLap BandOther
If other, please list.
YesNo
YesNo
YesNo
Consent & Acknowledgment
I understand that GLP‑1 medications are not a guarantee of weight loss and results vary.

I understand potential side effects may include nausea, vomiting, diarrhea, constipation, reflux, fatigue, and injection site reactions.

I understand compounded medications are not FDA‑approved but are legally prescribed when clinically appropriate.

I understand I must follow dosing instructions and attend follow‑up visits as recommended.

I confirm I am physically located in an eligible state at the time of my visit.

I understand payment, membership, and refill policies apply.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Patient Medical Weight Loss GLP1 Intake Form

PATIENT LOCATION & VISIT TYPE

Medical History

Lifestyle & Weight Management Goals

Additional Screening

Consent & Acknowledgment