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*
In-Person (Dallas, TX)Telehealth
Note: Telehealth is only available in TX, CO, FL, VT, VA, WA, CT, IA.
Program Selection
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 $100 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
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:*
YesNo
If it has been longer than 2 weeks off medications we may need to start you over at the lower starting dose
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
YesNo
If yes, please list diabetes medications:
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:
YesNo
If yes, how often and how much?
YesNo
If yes, what type and how often?
YesNo
If yes, please specify:
Additional Screening
YesNo
If yes, please describe:
YesNo
If yes, please describe:
YesNo
If yes, please describe:
YesNo
If yes, please describe:
Fees & Policy Acknowledgments
I acknowledge
I acknowledge
I acknowledge
I acknowledge
I acknowledge
I acknowledge
I acknowledge
I acknowledge
I acknowledge
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