GLP/GIP Micro-dosing Questionnaire

GLP/GIP Micro-dosing Questionnaire

Intake & Interest Form
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Age
Years
Height
Feet, Inches
Weight
LB
Type 1 diabetesDiabetic retinopathyBariatric surgeryGastroparesisMalabsorptionStomach diseaseKidney diseaseGallbladder diseasePancreatic diseaseCancer (other than skin cancer)None of these
Multiple endocrine neoplasia type 2 (MEN2)Serious allergic reaction to Zepbound, Mounjaro or compounded tirzepatideSerious allergic reaction to Ozempic, Wegovy or compounded semaglutideMedullary thyroid cancerNone of these
YesNoSomeone in my family had thyroid cancer, but I'm not sure which type
Currently pregnantCurrently breastfeedingPlanning to become pregnantTaking oral birth control pillsOn another form of birth controlI do not have to worry about becoming pregnantOther
Besides those you have already identified in the previous questions, are there any other medical conditions you are currently managing?
InsulinSulfonyureals (ex: glipizide, glimepiride, glyburide)Semaglutide (ex: Ozempic, Wegovy)Tirzepatide (ex: Zepbound, Mounjaro)None of these
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.
YesNo
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