GLP Intake

  • New Patient Medical Weight Loss GLP1 Intake Form

    📋 Please fill out, sign, and submit the intake form prior to your consultation.
  • Are you a current patient at Partida Corona Medical Center?
  •  - -
  • Format: (000) 000-0000.

  • Patient Intake

  • Are you currently pregnant, trying to conceive, or breastfeeding?**
  • GLP-1 medications  are not recommended during pregnancy or while trying to conceive due to potential risks to fetal development

    GLP-1 medications  are not recommended during pregnancy or while trying to conceive due to potential risks to fetal development

  • Medical History Do you have any of the following conditions? (Check all that apply)**
  • 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.**
  • Do you take any daily medications, prescribed or over the counter?**
  • Do you have any medication allergies?*
  • Have you previously used a GLP-1 receptor agonist (Semaglutide, Tirzepatide, Ozempic, Wegovy, Mounjaro, etc.)?**
  • What best describes why a compounded GLP-1 medication is being considered or required for your care? (Select all that apply)**
  • Do you currently take insulin or other diabetes medications?*

  • Lifestyle & Weight Management Goals

  • What is your primary reason for seeking GLP-1 therapy?*
  • How many times per week do you exercise?*
  • Do you follow any specific diet plan?**
  • Do you consume alcohol*
  • Do you smoke or use tobacco/nicotine products*
  • Do you use any recreational drugs, including marijuana?*

  • Additional Screening

  • Have you ever undergone a weight loss procedure?*
  • Which procedure have you had performed?
  • Have you had any significant weight fluctuations in the past year?**
  • Do you experience frequent nausea, vomiting, or acid reflux?*
  • Do you have any history of hypoglycemia (low blood sugar)?*

  • Consent & Acknowledgment

  •  GLP‑1 Inhibitors for Weight Management: Semaglutide and Tirzepatide
    Glucagon‑like peptide‑1 (GLP‑1) inhibitors are a class of medications originally developed for type 2 diabetes that have become highly effective tools for chronic weight management and obesity treatment. These agents mimic the effects of the natural GLP‑1 hormone, which regulates appetite, glucose levels, and gastrointestinal motility.


    Benefits
    • Significant weight reduction: Both semaglutide (brand names: Wegovy®, Ozempic®) and tirzepatide (brand names: Mounjaro®, Zepbound®) can result in 15–20% average weight loss with proper diet and lifestyle modifications.
    • Improved metabolic health: They enhance insulin sensitivity, reduce fasting glucose, and lower HbA1c, helping prevent or manage diabetes.
    • Cardiovascular benefits: Trials show reduced risk of major cardiovascular events in high‑risk populations, including those with obesity or diabetes.
    • Appetite regulation: These medications act on central receptors to reduce hunger and cravings, promoting sustainable satiety.
    • Potential improvements in fatty liver disease, blood pressure, and inflammation have also been observed.
    Contraindications
    GLP‑1 inhibitors should not be used in the following circumstances:
    • Personal or family history of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia type 2 (MEN2).
    • Prior severe hypersensitivity or allergic reaction to the medication.
    • Pregnancy or intent to become pregnant.
    • History of pancreatitis (use with caution or avoid if recurrent).
    • Severe gastrointestinal disease such as gastroparesis.
    Patients with kidney disease, gallbladder disease, or taking insulin or sulfonylureas should use GLP‑1 inhibitors under close medical supervision to minimize risk of hypoglycemia or other adverse effects.

     

     

    • 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.
  • Do you understand the information above, including the potential benefits, risks, and contraindications, and consent to be contacted about discount or savings offers for treatment with semaglutide or tirzepatide?*

  • Payment

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      GLP Initial Doctors visit

      Initial Doctors visit will be credited towards first months GLP-1  upon approval from Doctor.  If you are not a candidate for GLP-1's your doctors visit will not be refunded.

      $55.00
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      Total
      $0.00

      Payment Methods

      creditcard
      After submitting the form, you will be redirected to Apple Pay to complete the payment.
      After submitting the form, you will be redirected to Google Pay to complete the payment.
      After submitting the form, you will be redirected to Cash App Pay to complete the payment.
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