New Patient Medical Weight Loss & GLP-1 Intake Form

New Patient Medical Weight Loss & GLP-1 Intake Form

Please complete all sections accurately to help us understand your medical history and goals.
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Location & Visit Type
State of Residence*
Visit Type*

In-Person (Dallas, TX)Telehealth
Note: Telehealth is only available in TX, CO, FL, VT, VA, WA, CT, IA.
Program Selection
Which program(s) are you interested in?*

Compounded Semaglutide — Tier 1 StarterCompounded Semaglutide — Tier 2 TherapeuticCompounded Semaglutide — Tier 3 Max DoseCompounded Tirzepatide — Tier 1 StarterCompounded Tirzepatide — Tier 2 TherapeuticCompounded Tirzepatide — Tier 3 Max DoseWegovy® via NovoCareZepbound® via LillyDirectNot sure — I'd like my provider to recommend
A $125 initial consultation fee is required for all new weight loss patients. If labs are needed, a flat cash-pay fee of $150 applies, or labs may be billed to insurance through Quest Diagnostics. Please note that cash-pay pricing of $150 is not guaranteed if utilizing insurance, as we are unable to verify insurance benefits in advance. Optimize by JaeNix is not responsible if insurance does not cover lab costs, and any remaining balance is the responsibility of the patient.
Medical History
Please check any conditions you have been diagnosed with:*

Hypertension (high blood pressure)High cholesterolDiabetes (Type 1 or 2)Thyroid disorderHeart diseaseKidney diseaseLiver diseaseGallbladder diseasePancreatitisCancerNone of the aboveOther
List all current medications (include dose and frequency):*
Do you have any allergies? Please list:*
Have you used GLP-1 medications before?*

YesNo
If it has been longer than 2 weeks off medications we may need to start you over at the lower starting dose
Which GLP-1 medication(s) have you used?

Semaglutide (generic)OzempicWegovyRybelsusTirzepatide (generic)MounjaroZepboundOther
If other, please specify:
How long did you use this medication?
What was your last dose in mg?
Date of last dose:

MonthDayYear
Date
Are you currently taking diabetes medications?*

YesNo
If yes, please list diabetes medications:
Are you pregnant, planning pregnancy, or breastfeeding?*

PregnantPlanning pregnancyBreastfeedingNone of the above
Lifestyle & Goals
Current Weight (lbs)*
Height (feet/inches)*
Goal Weight (lbs)*
How often do you exercise per week?
Describe your typical diet:
Do you consume alcohol?*

YesNo
If yes, how often and how much?
Do you use tobacco/nicotine products?*

YesNo
If yes, what type and how often?
Do you use recreational drugs?*

YesNo
If yes, please specify:
Additional Screening
Have you had prior weight loss procedures (e.g., surgery)?*

YesNo
If yes, please describe:
Have you experienced significant weight fluctuations?*

YesNo
If yes, please describe:
History of nausea or reflux?*

YesNo
If yes, please describe:
History of hypoglycemia (low blood sugar)?*

YesNo
If yes, please describe:
Fees & Policy Acknowledgments
I understand that GLP-1 medications are not a guarantee of weight loss and that results vary by individual.*

I acknowledge
I understand that potential side effects may include nausea, vomiting, diarrhea, constipation, reflux, fatigue, and injection site reactions.*

I acknowledge
I understand that compounded medications are not FDA-approved but are legally prescribed when clinically appropriate and determined by my provider.*

I acknowledge
I understand that I must follow dosing instructions and attend follow-up visits as recommended by my provider.*

I acknowledge
I confirm that I am physically located in an eligible state (TX, CO, FL, VT, VA, WA, CT, or IA) at the time of my telehealth visit.*

I acknowledge
I understand that the $125 initial consultation fee is non-refundable.*

I acknowledge
I understand that if a prior authorization is required by my insurance for Wegovy® or Zepbound®, a $99 PA fee applies per submission, is non-refundable once submitted, and does not guarantee approval.*

I acknowledge
I understand that compounded GLP-1 medications are considered when brand-name options are not accessible, affordable, or clinically appropriate, and this is determined by my provider.*

I acknowledge
I understand that GLP-1 medications are contraindicated with a history of medullary thyroid carcinoma (MTC), Multiple Endocrine Neoplasia type 2 (MEN-2), active pancreatitis, or severe gastroparesis, and I confirm none of these apply to me or I will disclose them to my provider.*

I acknowledge
I confirm that all information provided in this form is accurate and complete to the best of my knowledge.*

I acknowledge
Signature & Submission
By signing below, I confirm that all information provided in this form is accurate and complete to the best of my knowledge. I consent to a telehealth or in-person medical evaluation by Optimize by JaeNix, led by Jessica Boggs, APRN, under the medical oversight of Simal Patel, MD.
Signature*
Date*

MonthDayYear
Date
Signature*
Date*

MonthDayYear
Date
Should be Empty:

New Patient Medical Weight Loss & GLP-1 Intake Form

Patient Information

Location & Visit Type

Program Selection

Medical History

Lifestyle & Goals

Additional Screening

Fees & Policy Acknowledgments

Signature & Submission