• Hamel Direct Care — Weight management

    Complete this form for a non-urgent care request. Select Submit to send your answers to Hamel Direct Care for review. Submitting a form does not guarantee an appointment, prescription, or treatment. For an emergency, call 911. Forms are not monitored continuously.
  • Complete this form for a non-urgent care request. Select Submit to send your answers to Hamel Direct Care for review. Submitting a form does not guarantee an appointment, prescription, or treatment. For an emergency, call 911. Forms are not monitored continuously.
  • Date of birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently experiencing an emergency or unable to keep yourself safe?*
  • Format: (000) 000-0000.
  • Safe to leave a voicemail?*
  • Format: (000) 000-0000.
  • Is someone completing this form on the patient’s behalf?*
  • List prescription medicines, nonprescription products and supplements. Use None or Unknown where appropriate.
  • Current medications
  • Any medication or product allergies?*
  • Use measured values and dates where known. Describe any information you would prefer to discuss directly.
  • Describe your goals and current or recent weight-management treatment. A request for review does not authorize a medication or dose change.
  • Request type*
  • Are you currently taking, or have you recently taken, a weight-management medicine?*
  • Use measured values with units, dates and sources; write Unknown if unavailable. A pharmacy preference does not assign a pharmacy or select a medicine. The practice may work with multiple compounding pharmacies; the actual product and full quote need confirmation. Compounded products are not FDA-approved.
  • Do you have a pharmacy preference?*
  • Answer each question and explain Yes or Unsure. These answers require clinician interpretation; they do not automatically establish treatment eligibility.
  • Personal or family medullary thyroid cancer (MTC) or MEN2?*
  • Serious allergic reaction to semaglutide, tirzepatide, or a similar medicine?*
  • Pancreatitis or gallbladder disease?*
  • Severe slow stomach emptying, persistent vomiting, or severe bowel symptoms?*
  • Kidney disease or recent dehydration?*
  • Diabetes, low blood sugar episodes, or diabetic eye disease?*
  • Using insulin, a sulfonylurea, another GLP-1, or another tirzepatide product?*
  • Tell your clinician about pregnancy, pregnancy plans, breastfeeding, contraception and planned procedures. Product-specific instructions require an individualized discussion with your clinician.
  • Pregnant or possible pregnancy?*
  • Planning pregnancy or breastfeeding?*
  • Using an oral contraceptive pill?*
  • Planned procedure with general anesthesia or deep sedation?*
  • Before treatment, discuss the proposed medicine, alternatives, benefits, risks, administration instructions and monitoring. The clinician must address your questions before treatment-specific consent.
  • Update your progress, current treatment, medication use and any changes since the last review.
  • A refill or dose change requires clinician instructions. Please submit any update for review. Seek immediate care for an emergency.
  • Follow-up route requested*
  • New severe symptoms or an urgent health concern?*
  • Pregnancy possibility/plans, breastfeeding, or contraception change if relevant?*
  • Upcoming procedure with anesthesia / deep sedation?*
  • These are draft care preferences for discussion. Completing or printing this form does not create a signed consent or authorize treatment. The practice provides the applicable consent document and discussion before treatment.
  • General care decision*
  • Telehealth can involve video or later clinician review of submitted information. A visit, examination, tests or referral may still be needed. Forms are for non-urgent requests and are not monitored continuously. You may decline or ask questions before agreeing to care.
  • My telehealth decision*
  • The practice must supply its current Notice of Privacy Practices before asking you to acknowledge receipt. Use this form to request a copy or ask questions; it is not a receipt acknowledgment.
  • What would you like to request?*
  • Use this form to ask about visit fees, medication-inclusive quotes, laboratory costs and payment terms. The practice must provide the actual written quote and any required estimate. No payment or financial agreement is created here.
  • What would you like clarified before any charge?*
  • Selected noncontrolled weight-management, ED and PE care may use clinician review without a scheduled appointment when appropriate. A clinician may require more information, testing or a visit. These are draft preferences only; they do not request a prescription.
  • Online assessment decision*
  • Should be Empty: