Formulário Médico iDoctor EUA

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Partner referral?

Partner's name?

Legal Name

First NameMiddle NameLast Name

E-mail Address

example@example.com

Phone Number

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

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you physically located in your country of residence at the moment?

Date of Birth

Date

Are you pregnant, breastfeeding, or planning to become pregnant within the next 12 months?

What is your primary motivation?

How much weight would you like to lose?

Height (feet)

Height (inches)

Current Weight (lbs)

Desired Weight (lbs)

Your BMI

Do you have any of the following conditions?

Se você afirmou ter Diabetes, informe qual:

Have you previously used a GLP-1 medication?

Personal history of medullary thyroid carcinoma (MTC)?

Medullary thyroid carcinoma is a rare type of thyroid cancer. We ask this question because tirzepatide is not recommended for individuals with a personal or family history of MTC or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

Family history of medullary thyroid carcinoma (MTC)?

Personal or family history of MEN2 syndrome?

Multiple Endocrine Neoplasia Type 2 (MEN2) is a rare genetic condition that increases the risk of tumors affecting the thyroid and other glands. We ask this question because tirzepatide is not recommended for individuals with a personal or family history of MEN2. Please select “Yes” if you or a close family member has been diagnosed with this condition.

History of pancreatitis?

Severe kidney disease or dialysis?

Type 1 diabetes?

History of major depression or suicidal thoughts?

History of an eating disorder?

Do you have any surgery scheduled within the next 30 days?

Are you currently taking insulin or a sulfonylurea medication?

How often do you consume alcohol?

Are you currently under the care of another healthcare provider?

Known Allergies

Current Medications

Zephra is a 503A compounding pharmacy. Why are you seeking a personalized compounded formulation instead of a commercially available medication?

Is there anything else your physician should know?

1. I confirm that all information provided is true, complete, and accurate.

2. I understand that medications compounded under Section 503A are not FDA-approved. However, the pharmacy is properly registered with the FDA. The FDA does not independently verify the safety, effectiveness, or quality of compounded medications. The pharmacy provides a Certificate of Analysis (COA) for quality assurance.

3. I understand the FDA safety warning regarding tirzepatide and the symptoms I should watch for. I agree to seek medical attention promptly if I experience symptoms such as a lump or swelling in the neck, difficulty swallowing, shortness of breath, or persistent hoarseness

4. I understand that my medication is compounded by a licensed 503A pharmacy pursuant to an individualized prescription.

5. I understand that Zephra Pharmacy is not affiliated with, endorsed by, or licensed by the manufacturer of any reference brand-name medication.

6. I understand the common side effects (including nausea, vomiting, and diarrhea) and the rare but serious risks (including pancreatitis, hypoglycemia, and kidney injury) associated with treatment.

7. I understand that medication cannot be returned or refunded once it has been dispensed.

9. I agree to the Telemedicine Informed Consent Form.

10. I agree to the Terms of Use, Privacy Policy, and HIPAA Notice of Privacy Practices.

11. I consent to the use of electronic signatures in accordance with the Electronic Signatures in Global and National Commerce Act (E-SIGN Act) and the Uniform Electronic Transactions Act (UETA).

Electronic Signature

iDoctor Intake Medical Form

Eligibility & Goals

About You

Your Goals

Medical Profile

Medical Safety Screening

Medications & Lifestyle

Medical Necessity

Consent

Legal Consents

Payment & Signature