GLP/GIP Micro-dosing Questionnaire

Full Name

First NameLast Name

Date of Birth

MonthDayYear

Age

Years

Height

Feet, Inches

Weight

LB

What city are you located in? (for scheduling purposes)

Have you ever had any of the following? (select all that apply)

Has anyone in your family ever had medullary thyroid cancer (MTC)? (Note: MTC is not the same as papillary, follicular or anaplastic thyroid cancers)

How would you describe your reproductive status?

Besides those you have already identified in the previous questions, are there any other medical conditions you are currently managing?

Are you currently taking any of the following medications? (select all that apply)

Please provide a phone number or email address to follow up. Thank you!

1.) Membership Terms

This membership includes a once weekly subcutaneous self-injection of tirzepatide.

The medication is offered in a 2 month supply, renewable as desired. We provide the prescription, medication, injection supplies, and teaching/support along the way!

If approved by our medical director, you can expect pharmacy fulfillment 2-10 business days.

Investment: $239/month, billed in 2 months at a time.

2.) All the information I have given is correct.

All the information on this form is correct and to the best of my knowledge. I have sought and followed any necessary medical advice. I understand that all the information given will be kept confidential.

*Submission of this form does not result in obligation to particiate in this program.

I agree to the above terms & conditions