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Treatment
Treatment are you requesting?
Select
Semaglutide
Tirzepatide
Tirzepatide
Have you ever had an adverse or allergic reaction to Tirzepatide, or to any of its ingredients:
No
Yes
Have you ever had an adverse or allergic reaction to another GLP-1 receptor agonist such as, but without limitation to, Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)
No
Yes
Have you taken or are you currently taking any of the following medications- Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro/Zepbound), Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)?
No
Yes
which ones and what dose?
Do you have a personal medical history involving any of the following medical conditions?
Diabetes Mellitus
No
Yes
Which type?
Select
Type 1
Type 2
Diabetic Retinopathy
No
Yes
Diabetic Ketoacidosis
No
Yes
Pancreatitis
No
Yes
Gallbladder Disease
No
Yes
Medullary Thyroid Carcinoma
No
Yes
Multiple Endocrine Neoplasia
No
Yes
Kidney disease/kidney insufficiency or transplant/Acute Kidney Injury
No
Yes
Stomach Problems
No
Yes
Bariatric Surgery or other GI Surgery
No
Yes
Liver Disease/Cirrhosis
No
Yes
Leber Hereditary Optic Neuropathy
No
Yes
Are you Pregnant
No
Yes
Are you currently experiencing, or have you experienced, depression with a history of suicidal attempts, suicidal thoughts, or suicidal ideation
No
Yes
Do you have any family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC)
No
Yes
Are you currently receiving Chemotherapy
No
Yes
Are you taking any of the following medications
Abiraterone Acetate
No
Yes
Somatrogon-GHLA
No
Yes
Chloroquine
No
Yes
Flouroquinolones
No
Yes
Hydroxychloroquine
No
Yes
Insulin
No
Yes
Insulin Secretagogues
No
Yes
GLP-1s
No
Yes
Semaglutide
Have you ever had an adverse or allergic reaction to Semaglutide, or to any of its ingredients:
No
Yes
Have you ever had an adverse or allergic reaction to another GLP-1 receptor agonist such as, but without limitation to, Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)
No
Yes
Have you taken or are you currently taking any of the following medications- Semaglutide (Ozempic/Wegovy), Tirzepatide (Mounjaro/Zepbound), Dulaglutide (Trulicity), Exenatide extended release (Bydureon bcise), Exenatide (Byetta), Liraglutide (Victoza, Saxenda), and Lixisenatide (Adylyxin)?
No
Yes
which ones and what dose?
Do you have a personal medical history involving any of the following medical conditions?
Diabetes Mellitus
No
Yes
Which type?
Select
Type 1
Type 2
Diabetic Retinopathy
No
Yes
Diabetic Ketoacidosis
No
Yes
Pancreatitis
No
Yes
Gallbladder Disease
No
Yes
Medullary Thyroid Carcinoma
No
Yes
Multiple Endocrine Neoplasia
No
Yes
Kidney disease/kidney insufficiency or transplant/Acute Kidney Injury
No
Yes
Stomach Problems
No
Yes
Bariatric Surgery or other GI Surgery
No
Yes
Liver Disease/Cirrhosis
No
Yes
Leber Hereditary Optic Neuropathy
No
Yes
Are you Pregnant
No
Yes
Are you currently experiencing, or have you experienced, depression with a history of suicidal attempts, suicidal thoughts, or suicidal ideation
No
Yes
Do you have any family history of Multiple Endocrine Neoplasia, Type 2, (MEN 2) or Medullary Thyroid Carcinoma (MTC)
No
Yes
Are you currently receiving Chemotherapy
No
Yes
Are you taking any of the following medications
Abiraterone Acetate
No
Yes
Somatrogon-GHLA
No
Yes
Chloroquine
No
Yes
Flouroquinolones
No
Yes
Hydroxychloroquine
No
Yes
Insulin
No
Yes
Insulin Secretagogues
No
Yes
GLP-1s
No
Yes
SORRY YOU DO NOT QUALIFY
Lifestyle Info
Do you Smoke:
No
Less then one pack a day
One Pack per day
Two Packs per day
More then 2 packs per day
Do you Drink:
No
Never
Occasionally
Daily
Only on weekends
Caffeine:
None
Coffee
Tea
Cola
Energy Drinks
# of Cups/Cans Per Day:
Do you Exercise:
Sedentary (No exercise)
Mild Exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional Vigorous Exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular Vigorous Exercise (i.e., work or recreation 4x/week for 30 minutes)
Are you dieting:
No
Yes
Are you on a physician prescribed medical diet?
No
Yes
Personal Medical History
Acid Reflux GERD: Yes
No
Unknown
Acne: Yes
No
Unknown
Arthritis: Yes
No
Unknown
Asthma: Yes
No
Unknown
Afib: Yes
No
Unknown
Autoimmune: Yes
No
Unknown
Bleeding Disorders: Yes
No
Unknown
Cancer: Yes
No
Unknown
Congestive Heart Failure: Yes
No
Unknown
COPD: Yes
No
Unknown
Coronary Artery Disease: Yes
No
Unknown
Chronic Fatigue Syndrome: Yes
No
Unknown
Crohn's Disease: Yes
No
Unknown
Dementia: Yes
No
Unknown
Depression: Yes
No
Unknown
Diabetes: Yes
No
Unknown
Difficulty Urinating: Yes
No
Unknown
Eczema: Yes
No
Unknown
Epstein Barr Virus: Yes
No
Unknown
Fever Chills: Yes
No
Unknown
Fibromyalgia: Yes
No
Unknown
Gastrointestinal Disorders: Yes
No
Unknown
Glaucoma: Yes
No
Unknown
Heart Disease/Heart Attack: Yes
No
Unknown
have you had stents or open heart?
No
Yes
Hemachromatosis: Yes
No
Unknown
Hepatitis: Yes
No
Unknown
Hernia: Yes
No
Unknown
Hives: Yes
No
Unknown
High Blood Pressure: Yes
No
Unknown
High Cholesterol: Yes
No
Unknown
HIV: Yes
No
Unknown
Hyperthyroidism: Yes
No
Unknown
Hypothyroidism: Yes
No
Unknown
Irritable Bowel Syndrome: Yes
No
Unknown
Kidney Disease: Yes
No
Unknown
Liver Disease: Yes
No
Unknown
Lung Problems: Yes
No
Unknown
Lupus: Yes
No
Unknown
Migraines: Yes
No
Unknown
Mononucleosis: Yes
No
Unknown
Multiple Sclerosis: Yes
No
Unknown
Nasal Polyps: Yes
No
Unknown
Overweight: Yes
No
Unknown
Parathyroid: Yes
No
Unknown
Psoriasis: Yes
No
Unknown
Psychiatric Disorders: Yes
No
Unknown
Rosacea: Yes
No
Unknown
Sarcoidosis: Yes
No
Unknown
Seizures: Yes
No
Unknown
Sickle Cell Anemia: Yes
No
Unknown
Sleep Apnea: Yes
No
Unknown
Staph Skin Infection: Yes
No
Unknown
Stroke: Yes
No
Unknown
Thrombophlebitis: Yes
No
Unknown
Ulcerative Colitis: Yes
No
Unknown
Underweight: Yes
No
Unknown
Vitiligo: Yes
No
Unknown
Other: Yes
No
Unknown
Family Medical History
Alcohol Abuse: Yes
No
Unknown
Aneurysm: Yes
No
Unknown
Arthritis: Yes
No
Unknown
Asthma: Yes
No
Unknown
Autoimmune: Yes
No
Unknown
Birth Defects: Yes
No
Unknown
Blood Clotting: Yes
No
Unknown
Cancer: Yes
No
Unknown
What type of cancer?
COPD: Yes
No
Unknown
Deep Vein Thrombosis: Yes
No
Unknown
Dementia: Yes
No
Unknown
Depression: Yes
No
Unknown
Diabetes: Yes
No
Unknown
Eye Disease: Yes
No
Unknown
Heart Attack: Yes
No
Unknown
Heart Disease: Yes
No
Unknown
Hemochromatosis: Yes
No
Unknown
High Blood Pressure: Yes
No
Unknown
High Cholesterol: Yes
No
Unknown
Kidney Disease: Yes
No
Unknown
Liver Disease: Yes
No
Unknown
Lung Disease: Yes
No
Unknown
Osteoporosis: Yes
No
Unknown
Psychiatric Disorders: Yes
No
Unknown
Stroke: Yes
No
Unknown
Thyroid Disease: Yes
No
Unknown
Ulcers: Yes
No
Unknown
Health Record
LEAVE BLANK IF THERE ARENT ANY
Medical Conditions
None.
Condition:
Comment:
Date Of Onset:
Drug Allergies
None.
Drug Name:
Reaction:
Patient Allergies
None.
Name:
Reaction:
Surgeries
None.
Surgery:
Comment:
Date Of Surgery:
Medications
None.
Name:
Comment:
Card Number
Expire (mm/yy)
Card CODE
Payment Authorization
By Checking this box I authorize a (1) one time charge of $39.99 to the credit card listed in this authorization form. The payment authorization is for the service of a (1) time non refundable async telemedicine consultation with a licensed doctor in your state. Your doctor consultation may be reimbursable with your insurance provider. I certify that I’m an authorized user of this card and will not dispute this payment with my card company, so long as the transaction corresponds to the terms and conditions. You agree that we or our systems may contact you via email, text or calls if needed. Any dispute will result in my information being reported to Cardharder Verification system that other merchants use to see if the cardholder is worth working with.
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