Hormone Therapy & Weight Loss Treatment Intake Form

Hormone Therapy & Weight Loss Treatment Intake Form

Please fill out this form accurately to help us understand your health background and tailor our treatment options accordingly.
Patient Name & Information

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Gender
Date of Birth

MonthDayYear
Date
Referred By
Treatment Interest
Do you have health insurance?
Have you recently discontinued the use of a weight loss medication? If so, please tell us which brand, when you stopped using the medication and at what dose/strength did you stop?
Are you currently on a Semaglutide/Ozempic, Mounjaro, or any other weight loss medication and switching to us? If so, please tell us why and where you are currently at in the process.
Medical History
Please Select All That May Apply
Do you have any of the following allergies?
Please list any current medication.
How much are you looking to lose?
Are you pregnant or looking to become pregnant?
Are you breastfeeding?
Current Weight
Desired Weight
Insurance Provider (if applicable)
Current Medications
Pre-existing Medical Conditions
Allergies or Adverse Reactions
Lifestyle Factors (e.g., alcohol, tobacco, drug use)
Do you have a history of hormone-related conditions?
Are you interested in Testosterone Replacement Therapy (TRT)?
Do you use tobacco products?
Do you consume alcohol regularly?
I understand and acknowledge the following:

I am beginning GLP-1 therapy (e.g., Semaglutide or Tirzepatide) under the supervision of a licensed medical provider. This treatment may include benefits such as improved blood sugar regulation and appetite control, as well as potential risks or side effects. Possible side effects may include nausea, headache, constipation, dizziness, low blood sugar (if combined with other meds), or injection site discomfort. Rare complications may occur, and I agree to report any health changes or concerns to my provider immediately. This therapy may not be suitable for everyone, and treatment decisions will be made based on my labs, health history, and provider discretion.
I give consent for:

Use and disclosure of my protected health information (PHI) as needed for treatment, lab work, pharmacy fulfillment, and payment, in accordance with HIPAA. Use of telehealth consultations for medical evaluations, prescriptions, and follow-up care. Sharing accurate and updated health history to ensure safe treatment. Arbitration in the event of a treatment dispute. Optional use of de-identified images (if taken) for medical records, education, or marketing.
Final Acknowledgment:
Digital Signature for Consent
Bloodwork

Bloodwork is required for our physician to review. This is to protect you. If you have bloodwork within the last 90 days, you can upload your results below. If you do not have bloodwork, We can set you up at a Quest Diagnostic or LabCorp near you.
Please upload any bloodwork within the last 90 days

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Hormone Therapy & Weight Loss Treatment Intake Form

Medical History

Bloodwork