GLP-1 Weight Management Intake

Consent of Non-secure Forms of Electronic Communication

Electronic communication, via email, FaceBook/Instagram direct messaging and text, between you and the health care provider may not be secure. By signing below, you are acknowledging that you realize that email, direct messaging, and text communication does not provide a completely secure means of communication. While your health care provider will take reasonable efforts to protect your confidentiality, there is some risk that any protected health information contained in email, direct messaging or text may be disclosed to or intercepted by unauthorized third parties.

Use of more secure communications, such as phone or fax, are always an alternative that are available to you if you elect to not give consent to the following forms of communication.

I give permission for my health care provider to contact me using non-secure methods regarding reminders, scheduling, or other relevant matters, and I understand the risks involved.

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.

Full Name

First NameLast Name

Birthdate

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address

example@example.com

Gender

Please list any current medical conditions

Please List all current medications and supplements

Please list any allergies

Do you have a history of pancreatitis?

Do you have a history of bariatric surgery?

Personal or Family History of Thyroid Cancer? (MTC or MEN 2)

History of Gallbladder disease/Gallstones?

History of Type 1 or Type 2 Diabetes?

History of Kidney Disease or Renal Impairment?

History of Gastroparesis (Slow stomach emptying)?

History of Depression, Anxiety, or Suicidal Ideation?

Are you currently pregnant, breastfeeding, or planning to become pregnant in the next 3 months?

Do you have frequent heartburn or acid reflux? (GLP-1s can make it worse)

Do you experience chronic constipation (less than 3 bowel movements per week)

Have you been told you snore loudly or stop breathing when you sleep?

What was your weight at age 20?

What was your highest adult weight? (excluding pregnancy)

What is the most weight you have lost on a previous health journey?

Current Weight (lbs)

Height

Waist Circumference (inches)

Goal Weight (lbs)

Have you used GLP-1 medications before (e.g., Wegovy, Ozempic, Mounjaro)?

If yes, which one and what was your highest dose?

Reason for stopping

Are you currently taking Insulin or Sulfonylureas (e.g., Glipizide)?

How many meals do you eat per day?

On a scale of 1–10, how active is your daily life? (1 = Sedentary, 10 = Athlete)

How many hours of sleep do you typically get each night?

Average daily water intake (ounces)

Prices listed for medical provider and pharmacy for medications per 6-week dosing schedule. Prices fluctuate depending on your dosing level for GLP-1 medications, and you can expect your prices to be higher after 3-4 months which is when dosing escalates. Provider and Pharmacy fees are billed separately. Provider fees stay consistent throughout dosing adjustments.

Which medication are you interested in taking to assist you with your goals?

Feel free to let me know anything else about you!

Program Acknowledgment (please initial each):

Patient Signature

Date