Prescription Weight Loss Intake Form

Black box warning summary: Prescription weight loss injections may carry serious risks and side effects, including potential severe gastrointestinal symptoms (such as nausea, vomiting, diarrhea, and abdominal pain), dehydration, acute kidney injury, gallbladder disease, pancreatitis, and possible worsening of diabetic retinopathy. In some patients, these medications may also increase the risk of thyroid C-cell tumors; they should not be used in people with a personal or family history of medullary thyroid carcinoma or MEN2. These medications may also delay gastric emptying, which can affect tolerance of food and oral medications, and may contribute to hypoglycemia when used with other glucose-lowering drugs. Review all risks, warnings, benefits, and precautions with a qualified clinician before starting treatment.

Medical History and Laboratory Monitoring Acknowledgment

I affirm that, to the best of my knowledge, the health information, medication list, allergies, medical history, surgical history, and family history I have provided are complete, current, and truthful. I am not aware of any medical condition, symptom, pregnancy, medication, or other information that I have failed to disclose that could affect my eligibility for prescription weight-management treatment.

I understand that treatment eligibility and the need for laboratory testing are determined by the prescribing healthcare provider based on my medical history, current health, medications, symptoms, treatment duration, and clinical judgment.

For appropriate patients receiving lower-dose or short-term treatment, baseline laboratory testing may not be required unless the provider determines that testing is clinically indicated. I understand that I may request laboratory testing at any time, and the clinic will provide an order or laboratory slip when appropriate. Laboratory fees may be my responsibility.

Patients receiving continuous weekly prescription weight-management treatment for six months or longer must complete laboratory testing at least every six months, or more frequently when ordered by the healthcare provider, before continued prescribing. Treatment may be paused or discontinued if required laboratory testing or follow-up is not completed.

Stopping and restarting treatment does not automatically eliminate the need for laboratory testing. After an interruption, I may be required to complete a new evaluation, restart at a lower dose, and obtain laboratory testing when clinically indicated. The provider retains the right to require testing at any time based on my health history, symptoms, medication use, adverse effects, or time since my previous evaluation or laboratory testing.

I agree to immediately report any new diagnosis, medication, pregnancy or possible pregnancy, significant illness, severe or persistent side effect, hospitalization, or change in my health. I understand that withholding or providing inaccurate information may increase my risk of complications and may result in treatment being withheld or discontinued.

Required acknowledgment checkbox:

☐ I have read and understand the Medical History and Laboratory Monitoring Acknowledgment. I certify that the information I provided is complete and accurate to the best of my knowledge, and I agree to comply with laboratory testing and follow-up ordered by my healthcare provider.

 

Consent summary: By proceeding, you acknowledge review of the medication risks, understand the treatment expectations, and agree to discuss any questions before starting therapy.