Clone of Tirzepatide

1

Name* This field is required.

First Name

Last Name

2

Date of Birth* This field is required.

Date

3

Gender* This field is required.

4

Email* This field is required.

example@example.com

5

Phone Number* This field is required.

Please enter a valid phone number.

6

Are you currently pregnant or trying to become pregnant ?* This field is required.

Yes

No

Unsure

Not applicable / Male

7

Do you have any medication allergies? ( if none type n/a)* This field is required.

8

Please fill in your weight and height

9

Do you or an immediate family member have a history of medullary thyroid carcinoma (MTC), or do you have Multiple Endocrine Neoplasia type 2 (MEN 2)?

yes

No

Not sure

Other

11

Type a questionAre you currently using any of the following medications?

Semaglutide (Ozempic®, Wegovy®, compounded)

Tirzepatide (Mounjaro®, Zepbound®, compounded)

Insulin

Sulfonylureas (e.g., glipizide, glyburide)

12

Type a questionHave you ever been diagnosed with any of the following medical conditions? (Check all that apply)

History of pancreatitis

Severe gastrointestinal disorders (such as gastroparesis or severe delayed stomach emptying)

Gallbladder disease or gallstones

Chronic kidney disease or significant kidney problems

liver disease

13

Type a questionI understand that GLP-1 medications may not be appropriate for everyone, require medical evaluation, and do not guarantee weight-loss results.

I acknowledge and agree

14

Important Notice

All medical services, clinical evaluations, treatment decisions, and prescriptions are provided solely by Avenue U Medical Wellness PC.
TonedMD provides administrative and non-clinical management services only and does not practice medicine.

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“I acknowledge that I have read and understood the HIPAA Privacy Policy. I consent to the collection, storage, and use of my personal health information in accordance with the policy. I understand my rights under HIPAA and how my data will be used