Patient Medical Intake Form

Patient Medical Intake Form
This form helps us learn about your medical history. Please complete it to the best of your ability. Not every question is relevant to everyone.
Name:

First NameLast Name
DOB:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Primary Care Provider

We will reach out to your provider prior to your appointment to obtain your most recent lab results to ensure your safety when starting semaglutide therapy. If you have not had lab work, we will not be able to treat you until we can obtain this information.
Primary Care Provider:
Office Number:
Date of last physical:

MonthDayYear
Date
Do you have access to your most recent lab work (through an online portal, paperwork, etc.)?

YesNo

Patient Medical Intake Form
Allergies
Please list any allergies (including medications, food, and animals/insects) and the type of reaction
If your allergic reaction is anaphylaxis, do you have an epi-pen?

YesNo
Do you need a refill of your epi-pen?

YesNo
Medications

What medications (prescription and over-the-counter), vitamins, supplements, and herbs do you take (regularly and as needed)?

Primary Care Provider