Name
*
First Name
Last Name
email address
*
example@example.com
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Date of birth
*
-
Month
-
Day
Year
Date
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Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Height (ft/in.)
*
Weight (lbs)
*
BMI
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What are your primary goals for GLP-1 therapy?
*
Weight loss
Appetite control
Improved glucose control
Lower A1c
More stable hunger levels
Other
How long have you struggled with weight or appetite?
*
Medical History
Do you have or have you ever been diagnosed with any of the following? (Select all that apply)
*
Type 2 Diabetes
Prediabetes
PCOS
High cholesterol
High blood pressure
Sleep apnea
GERD
Kidney disease
Liver disease
Thyroid disease
History of pancreatitis
Gallbladder disease
Depression / Anxiety
None
Have you ever been told you have fatty liver or elevated liver enzymes?
*
Yes
No
Not Sure
Any personal or family history of medullary thyroid cancer or MEN2?
*
Yes
No
Not Sure
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you plan to become pregnant in the next 6 months?
*
Yes
No
Medications
List all current medications (prescription, OTC and supplements)
*
Are you currently taking any GLP-1 medications?
*
No
Semaglutide
Tirzepatide
Other
If you're currently taking any GLP-1 medications which dose are you on?
Have you used weight loss medications in the past?
*
Yes
No
If yes, which ones?
Do you have any allergies to medications?
*
Yes
No
If yes, which ones?
Lifestyle Factors
How would you describe your eating patterns?
*
How many days per week do you exercise?
*
What diets or approaches have you tried in the past?
*
Safety Questions
Any personal/family history of medullary thyroid carcinoma?
*
Yes
No
Not Sure
Any history of pancreatitis?
*
Yes
No
Any gallbladder disease?
*
Yes
No
Any chronic GI issues?
*
Yes
No
Any history of severe hypoglycemia?
*
Yes
No
Have you ever been told you have vitamin B6 toxicity, vitamin B12 sensitivity, or peripheral neuropathy?
*
Yes
No
Lab Access
Do you have insurance that covers lab work?
*
Yes
No
Other
When was your last A1c, CMP, CBC, or lipid panel?
*
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Telehealth and Medication Consent
I consent to telehealth services and understand that care is provided remotely without an in-person exam, may have limitations, and may require referral to in-person or emergency care.
*
Yes
I acknowledge that GLP-1 medications may have side effects including nausea, vomiting, constipation, diarrhea, gallbladder issues, or pancreatitis.
*
Yes
I confirm that I have answered all questions truthfully and to the best of my knowledge.
*
Yes
I understand medication is prescribed only after clinical review and monthly follow-up is required for refills.
*
Yes
I understand that compounded medications are prepared by a licensed compounding pharmacy and are not FDA-approved products. These medications are prescribed when clinically appropriate based on factors such as cost, access, or patient-specific needs. Nylix Health works only with pharmacies that meet applicable state and federal compounding standards.
*
Yes
I understand this service is not for medical emergencies and that I should call 911 or go to the nearest emergency department if urgent or emergent symptoms occur.
*
Yes
I acknowledge receipt of the HIPAA Notice of Privacy Practices and understand how my health information may be used and disclosed.
*
Yes
I understand that individual weight-loss results vary and are not guaranteed.
*
Yes
I authorize the release of my prescription and relevant health information to the pharmacy selected for dispensing my medication.
*
Yes
I understand GLP-1 medications carry a boxed warning related to thyroid C-cell tumors and should not be used in individuals with a personal or family history of medullary thyroid carcinoma (MTC) or MEN2.”
*
Yes
I understand that medical services are provided by a California licensed Nurse Practitioner and that provider consultation and follow-up fees are non-refundable once services have been rendered.
*
Yes
Signature
*
Date
*
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Month
-
Day
Year
Date
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