Weight Management Virtual Intake
Please complete all sections below so our clinical team can review your information before your visit.
Your Contact Information
Survey Being filled by:
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Self
Caregiver
Caregiver Name
Patient's First Name
Patient's Last Name
Home Address
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State
City
Postal Code
Date of birth
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Drop-Ship Address (if different from home address) {optional}
Patient's ID
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Upload Your ID here
Phone
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Email
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Patient Vitals & Basic Status
Weight (lbs)
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Height (feet)
Height (Inches)
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BMI
Pregnant?
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Yes
No
Breastfeeding?
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Yes
No
Last Menstrual Period (LMP)
Medical History
Medical History (please check all that apply)
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Hypertension
Hyperlipidemia
Hypothyroidism
Type 1 Diabetes
Type 2 Diabetes
PCOS
Joint Pain
Back Pain
Other →
Please describe about your medical history
Medications
Please list your all Medications here (Name & Dosage)
Social History
Alcohol Use?
Yes
No
Marijuana Use?
Yes
No
Illicit Drug Use?
Yes
No
Cigarette Use?
Yes
No
Surgical History
Please list your all Surguries below, if any: (Procedure & Year)
Allergies
Allergies? please describe below if any:
Clinical Screening
History (or 1st-degree family history) of Medullary Thyroid Cancer or Multiple Endocrine Neoplasia?
Yes
No
Ever had an allergic reaction to a GLP medication?
Yes
No
Diagnosed with gallbladder, pancreas, heart, or kidney problems?
Yes
No
Planning surgery in the near future?
Yes
No
Ever had thoughts of suicide or self-harm?
Yes
No
Planning to become pregnant in the near future, or currently breastfeeding?
Yes
No
Is BMI > 30?
Yes
No
Do you have a weight-related medical condition?
Yes
No
Has the patient been on GLP medications previously?
Yes
No
When was the last injection?
What was the last dose?
What was your weight before starting?
What was your BMI before starting?
Program And Medication Selection
Product
IMPORTANT:
Oral Semaglutide (Tablets) are only available for dropship at home.
Fulfillment channel
Commitment
Requested starting dose
What date you will be available for a Physician Consultation?
Please list your available time for the Physician Consultation?
Requesting compounded medication specifically?
Yes
No
Consent & Acknowledgments
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I understand FDA-approved vs. compounded medications and which one I am being prescribed.
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If compounded: I understand compounded preparations are not FDA-approved and my clinician has documented my individual clinical need.
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I understand the known risks discussed (nausea/vomiting, gastroparesis, bowel obstruction, depression/suicidal thoughts, pancreatitis, possible thyroid/endocrine cancer risk, and unknown long-term risks).
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I understand this is intended as a long-term treatment and that discontinuing before ~18 months is associated with regaining lost weight.
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I consent to virtual/telehealth evaluation.
Patient Legal Name
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Patient Signature Date
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Patient Signature
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Clear