Consultation Form
All order placements are patient specific and pending review. Please allow up to 48 business hours for our nurse practitioner to reach out to you for follow up on your request. Expect up to two weeks for delivery due to processing times with our compounding pharmacies.
I am aware that this form is HIPPA compliant and will only be used for the purpose of documentation in my Athena electronic health record (EHR) and for review during any telehealth or phone consultations. This information will not be shared with anyone outside of my healthcare team unless a release of information form has been completed and signed granting permission.
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Yes
I am aware that I must reside in NC to receive services with Coastal Wellness NC.
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Yes
I am aware that Coastal Wellness NC has the right to refuse completion of my Wellness Shop order based upon their assessment of my responses if there are any medical concerns and/or contraindications.
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Yes
Required Demographic Information for your Athena Health Chart
Legal Name
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First Name
Last Name
Preferred Nickname, if applicable:
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Shipping Address: Can NOT be a P.O. Box
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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Did anyone from CWNC help to answer your questions and/or help you place order?
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Please provide the staff member's name if applicable.
Medical Information To Be Reviewed and Verified During Your Consult
Please provide the number of units of Semaglutide that you are taking weekly:
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If you are experiencing any side effects with a GLP, please list them here:
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Height:
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Weight:
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BMI Calculator (duplicate information, but is a necessary calculation)
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Are you Pregnant or Breastfeeding?
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Yes
No
Not Applicable
I understand that GLP-1 medications may disrupt oral contraceptive efficiency, and that I will need to use a barrier method for four weeks upon each dose escalation.
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Yes
Not Applicable
Please list ALL allergies that you are aware of:
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Please list ALL medical conditions that you have been diagnosed with:
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Please list ALL medications with dosages and/or supplements you are currently taking:
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Please provide a brief description of your current health and wellness goals, as well as what progress you feel like you have made since beginning your program:
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Are you employed currently?
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Yes
No
I am retired
I am disabled
Self-employed
If working, what type of work do you do? Do you ever work night-shift?
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Are you currently or have you ever been a smoker? (Includes vaping)
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Never smoker
Former smoker
Current smoker
Trying to quit
Are you in recovery from substance use and/or alcohol use disorder?
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Yes
No
Do you consume alcohol?
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No alcohol consumption
Occasional
Moderate
Heavy
If you consume alcohol, how much and how often? This is important because alcohol can affect the way that your body responds to medication, as well as your overall weight management goals.
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Do you use any substances that may alter the mind and/or body in any way? (Includes CBD, Delta Products, Kava, Kratom, Marijuana)
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Yes
No
Sometimes
How much caffeine do you have on a daily basis? (coffee, soda, tea, energy drinks, etc.)
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What is your stress level currently (0-10 scale), and how do you manage stress? This is important because increased stress leads to cortisol and inflammatory changes in the body which can affect weight management.
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Approximately how many hours do you sleep per night? Do you wake feeling well rested?
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Do you have any physical limitations that make exercise difficult for you?
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How many times per week do you work out intentionally?
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None currently
1 day per week
2-3 days per week
4-5 days per week
5+ days per week
What does your physical activity look like? (cardio, weights, yoga, biking, etc.)
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What type of diet do you currently follow?
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Regular - No Restrictions
Carnivore
Paleo
Pescatarian
Vegetarian
Vegan
Calorie Restricted
Carbohydrate Restricted
Keto Diet
Intermittent Fasting
How much water do you drink daily?
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Do you have any questions or concerns for your provider?
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Acknowledgement of Understanding
I Understand that Coastal Wellness NC does NOT replace the routine care of a Primary Physician:
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Yes
I understand that along with the benefits of any medical treatment or therapies, there are both risks and potential complications to treatment, as well as not being treated. Those risks and potential complications have been explained to me. I have not been promised or guaranteed any specific benefit from the administration of these therapies and no warranty or guarantee has been made regarding the results of treatment. I agree to proceed with treatment and to comply with recommended dosages.
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Yes
I agree to comply with requests for ongoing testing to assure proper monitoring of my treatments that may include laboratory evaluation of all aforementioned hormone levels and/or other diagnostic testing by my primary care physician, or other specialist.
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Yes
I agree to see my primary care physician, gynecologist, or other practitioner for regular monitoring and for preventative measures that may include but are not limited to complete physicals, rectal examinations and/or colonoscopy, EKG, mammograms, pelvic/breast exams, pap smears, prostate exams, PSA levels, etc. at least on a yearly basis. I agree to immediately report to my physician any adverse reaction or problem that might be related to my regimen with CWNC.
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Yes
I certify that I have read or have had this form read to me, and that I understand its contents. I agree not to undergo any treatments unless I fully understand the treatment and have discussed possible risks, benefits, and side effects with the provider. I agree to receive the treatment that has been recommended to me.
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Yes
I agree all the above health information submitted on the questionnaire is complete and accurate.
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Yes
I have read and understood the terms of this agreement
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Yes
Signature
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