Scientists One — Patient Evaluation (Demo)
Bilingual telehealth evaluation. Spanish · English · Portuguese. Your privacy is protected.
Basic Information
First Name
*
Last Name
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
City and State
*
FDA Safety Screening (ISI Compliance)
Personal or family history of medullary thyroid carcinoma (MTC)
*
Yes
No
History of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
*
Yes
No
Previous allergic reaction to a GLP-1 medication
*
Yes
No
History of pancreatitis
*
Yes
No
History of kidney disease or kidney transplant
*
Yes
No
History of gallbladder disease
*
Yes
No
History of diabetic retinopathy
*
Yes
No
History of gastroparesis (slow stomach emptying)
*
Yes
No
Currently pregnant or planning pregnancy within the next 2 months
*
Yes
No
Currently taking insulin or sulfonylureas
*
Yes
No
Currently taking another GLP-1 medication
*
Yes
No
Currently taking hormonal birth control
*
Yes
No
Current Health
Current weight (lbs)
*
Height (inches)
*
Existing medical conditions
Current medications
Consent
SMS Consent
*
I consent to receive SMS messages from Scientists One Health about my care, appointments, and payments. Message and data rates may apply. Reply STOP to unsubscribe.
Telehealth Consent
*
I understand this is a telehealth evaluation. I will be contacted by a licensed nurse practitioner in my preferred language within 24 hours.
Language Preference
*
Español
English
Português
Medication Interest
*
Wegovy
Ozempic
Mounjaro
Zepbound
Not sure - recommend for me
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SECTION 1: PAYMENT FIRST
Send $89 via Zelle to: (954) 451-8069 — Name: Camilo Morales Kopp — Then complete this form to confirm your evaluation
Date you sent Zelle payment
*
-
Month
-
Day
Year
Date
Payment method
*
Zelle
Venmo
Cash App
Amount sent
*
Zelle/Venmo transaction reference
Submit My Evaluation
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