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What was your sex assigned at birth? *This is a required field. *Male *Female *Other *

Are you currently pregnant, breastfeeding or planning to become pregnant? *This is a required field. *Yes *No *

Consent (pregnancy):

<p>Read the following for more information about this product and its potential side effects:</p><p>It is not safe to take these medications while pregnant or breastfeeding. The FDA advises that these medications may pose a risk to a developing fetus. Oral contraceptives alone may not be effective, as the medication can reduce their effectiveness. The FDA specifically recommends continuing oral contraception alongside a barrier method (like condoms) for the first month after starting a weight loss medication and for the first month after any dose increase. Alternatively, you can switch to a non-oral contraceptive method (such as an IUD or implant) before beginning the medication. After stopping the medication, you should continue using a backup method, such as condoms, for two months to ensure the medication has fully cleared your system before trying to conceive. Additionally, its safety during breastfeeding is unknown, so if you are nursing, consult your doctor to explore safer weight loss options.</p>

Consent (pregnancy) Confirmation: *This is a required field. *I acknowledge that I have read and understood the above information *I have read the above information and I do not wish to continue *

What is your height in feet and inches?

Feet *This is a required field.

Inches *This is a required field.

What is your weight in pounds?

lbs *This is a required field.

Your BMI

Consent (BMI):

The traditional use of weight loss medications is for individuals with a BMI of 30 and above or to those who are overweight who have associated health conditions. Using it for someone with a BMI range (27-29) without an accompanying health condition is termed "off-label." Using a medication "off-label" refers to the practice of prescribing a drug for a purpose, age group, dosage, or form of administration that is not included in the approved labeling by regulatory agencies like the U.S. Food and Drug Administration (FDA). While a medication undergoes rigorous testing for specific uses before receiving approval, healthcare providers may discover through clinical experience or research that it can be effective for treating other conditions. There may be benefits such as weight reduction for individuals within your range. If you agree to this off-label use, it's crucial to follow the prescribed regimen and report any concerns. Please discuss any questions with us.

Consent (BMI) Confirmation: *This is a required field. *I acknowledge that I have read and understood the above information *I have read the above information and I do not wish to continue *

Please check all current or past medical conditions:

Gastroparesis (Paralysis of your intestines)

Triglycerides over 600 at any point

Pancreatic cancer

Pancreatitis

Type 1 Diabetes

Hypoglycemia (low blood sugar)

Insulin-dependent diabetes

Thyroid cancer

Family history of thyroid cancer

Personal or family history of Multiple Endocrine Neoplasia (MEN-2) syndrome

Anorexia or bulimia

Current symptomatic gallstones

Hypertension (high blood pressure)

Dyslipidemia (high cholesterol or triglycerides)

Sleep Apnea

Osteoarthritis

Mobility issues which are impacted by body weight

Gastroesophageal reflux disease (GERD) related to body weight

Polycystic Ovary Syndrome with insulin resistance

Liver disease or conditions that affect the liver such as non-alcoholic fatty liver disease (NAFLD)

Heart disease or conditions that affect the heart

Metabolic Syndrome

Chronic Kidney Disease Stage 3 or greater

Syndrome of Inappropriate Antidiuretic hormone

Hypothyroidism, Hyperthyroidism, or Thyroid Issues

Prediabetes

Type 2 Diabetes

Gallbladder disease or past removal of your gallbladder

None of the above

Consent (Gallbladde):

<p>Read the following for more information about this product and its potential side effects.</p><p>Gallbladder disease information:</p><p>You noted that you have gallbladder disease or previous removal of our gallbladder. This medication may still be a good option. However, this medication can affect how the body handles fats and bile. If you have had your gallbladder removed, the body's ability to store and release bile is altered. Bile is crucial for digestion and fat absorption. This medication may increase the likelihood of gastrointestinal side effects in these individuals because it can alter fat metabolism and bile flow. This can lead to symptoms such as diarrhea and stomach pain.</p><p>Additionally, medications that affect digestion and appetite, like this medication, might alter the absorption and metabolism of other nutrients (like fat soluble vitamins such as vitamin A, D, E, and K) and medications. This is particularly important for those without a gallbladder, as their digestive system already operates differently from those with a functioning gallbladder. If you wish to move forward, it is important to eat smaller and more frequent meals. In addition, to ensure that you're receiving enough vitamins, you should avoid processed foods while eating plenty of fruits and vegetables, as well as considering the use of a multi-vitamin unless told by your provider to avoid these for other reasons.</p><p>If you have asymptomatic gallstones, please note that these medications and weight loss itself may result in gallstone formation which could result in the obstruction of the normal flow of bile which can result in infection, pancreatitis, and/or emergent need for gallbladder removal. It is important to receive prompt medical evaluation if symptoms appear as delayed action may result in serious harm or death if untreated.</p>

Consent (Gallbladde) Confirmation: *This is a required field. *I acknowledge that I have read and understood the above information *I have read the above information and I do not wish to continue *

Please tell us more about your medical condition(s) that you selected *This is a required field.

Please identify all your current medical conditions *This is a required field.

Please list all your current medications including dosages *This is a required field.

Please list all of your known allergies *This is a required field.

Have you had a gastric bypass in the past 6 months? *This is a required field. *Yes *No *

Are you allergic to any of the following: Ozempic (Semaglutide), Mounjaro (Tirzepatide), Wegovy (Semaglutide), Zepbound (Tirzepatide), Saxenda (Liraglutide), Trulicity (dulaglutide) ? *This is a required field. *Yes *No *

Do you take any of the following medications: Insulin Glimepiride (Amaryl), Meglitinides such as repaglinide or nateglinide, Glipizide (Glucotrol and Glucotrol XL), Glyburide (Micronase, Glynase, and Diabeta), Sitagliptin, Saxagliptin, Linagliptin, Alogliptin *This is a required field. *Yes *No *

Are you currently, or have you in the past two months, taken any of the following medications? *This is a required field. *Semaglutide (Ozempic, Wegovy, Rybelsus) *Tirzepatide (Zepbound, Mounjaro) *None of these *

Which Semaglutide (Ozempic, Wegovy, Rybelsus) dose most closely matches your most recent dose? *This is a required field. *Semaglutide 0.25mg *Semaglutide 0.5mg *Semaglutide 1mg *Semaglutide 1.5mg *Semaglutide 1.7mg *Semaglutide 2.4mg *

Which Tirzepatide (Zepbound, Mounjaro) dose most closely matches your most recent dose? *This is a required field. *Tirzepatide 2.5mg *Tirzepatide 5mg *Tirzepatide 7.5mg *Tirzepatide 10mg *Tirzepatide 12.5mg *Tirzepatide 15mg *

How would you like to continue your treatment? *This is a required field. *Stay at the same dose or equivalent dose *Increase the dose if a higher one is available, or continue with my current dose if it's already at the maximum *Decrease dose *

Do you have a picture of your current prescription? We need this photograph in order to validate your current dosage. *This is a required field. *Yes *No *

Please upload a picture of the prescription or bottle of your current GLP-1/GIP medication *This is a required field.

Preferred dose and supply duration *This is a required field. Choose an optionWegovyOzempic

Identity Verification. Upload a photo of a valid government-issued photo ID such as a driver’s license or passport which has your picture, name and date of birth clearly visible. If applicable, upload a photo of the front and the back especially when using a military ID as your date of birth is on the back of the card. Make sure the photo is clear and legible.

ID Photo Front

ID Photo Back

Full Body Image. To ensure the highest quality of care during your telemedicine consultation, we kindly request your assistance in providing a full-body clothed photo of yourself (please remain clothed but avoid wearing baggy apparel). The image should include your face to help facilitate verification of your identity. Please be assured that these images will remain private and will not be shared. The physician will use the picture solely for assessment purposes to better understand your health condition. Thank you for your cooperation and understanding in helping to provide comprehensive care remotely. (Tip: using a full length mirror can help you capture this image)

Full Body Image

What other information or questions do you have for the doctor?

Consent (Truthfulness):

Please attest to the following confirming that all information you have provided to us is true and complete. Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

Consent (Truthfulness) Confirmation: *This is a required field. *I have read and understand the above information and I do consent and wish to move forward with this treatment plan *I have read the above information and I do not wish to continue *

Consent (GLP-1 and GLP-1/GIP):

<strong>Indication for Use</strong><p>You are requesting treatment with a GLP-1 (Ozempic, Wegovy, or compounded semaglutide) or GIP/GLP-1 receptor agonist (Mounjaro, Zepbound, or compounded tirzepatide) medication as part of your treatment plan for the management of weight or obesity. These medications work by mimicking the action of incretin hormones, which help regulate blood sugar levels, promote feeling full, and reduce food intake.</p><p><strong>Potential Benefits</strong></p><ul><li>Weight loss or weight management</li> <li>Improved blood glucose control</li> <li>Reduced cardiovascular risk</li> <li>Potential improvement in overall metabolic health</li></ul><p><strong>Potential Side Effects</strong></p><p>While these medications can be beneficial, they may also cause side effects.  Although not common, these medications can result in emergency room visits, hospitalizations, or even death. Common and serious side effects include, but are not limited to:</p><ul><li><strong>Common Side Effects:</strong><ul><li>Nausea</li> <li>Vomiting</li> <li>Diarrhea</li> <li>Constipation</li> <li>Decreased appetite</li> <li>Indigestion</li></ul></li> <li><strong>Serious Side Effects:</strong><ul><li>Pancreatitis (inflammation of the pancreas)</li> <li>Hypoglycemia (low blood sugar), especially when used with other diabetes medications</li> <li>Gallbladder disease (e.g., gallstones)</li> <li>Kidney problems</li> <li>Allergic reactions (e.g., rash, itching, swelling)</li> <li>Gastroparesis (paralysis of the bowels)</li></ul></li></ul><p><strong>Risks and Considerations</strong></p><ul><li><strong>Pancreatitis:</strong> There is a risk of developing pancreatitis. If you experience severe abdominal pain, nausea, or vomiting, you should contact your healthcare provider immediately.</li> <li><strong>Thyroid Tumors:</strong> Animal studies have shown an increased risk of thyroid tumors with certain GLP-1 medications. Although this has not been confirmed in humans, please inform your healthcare provider if you have a history of thyroid cancer.</li> <li><strong>Hypoglycemia:</strong> When taken with other diabetes medications, particularly insulin or sulfonylureas, there is a risk of low blood sugar. It is important that your provider knows if any of these medications are added to your regimen. </li> <li><strong>Kidney Function:</strong> This medication may affect kidney function, particularly in patients with existing kidney disease. Regular monitoring of kidney function may be required.</li></ul><p><strong>Monitoring and Follow-up</strong></p><p>You will require regular follow-up visits to monitor your response to the medication and to assess for any side effects. We may intermittently ask for full-body selfie images to ensure that your reported weight is consistent.</p><p>I acknowledge the potential benefits, risks, and side effects of GLP-1 or GIP/GLP-1 receptor agonist medications. I understand the importance of regular monitoring and follow-up appointments. I consent to the use of GLP-1 or GIP/GLP-1 receptor agonist medications as part of my treatment plan for overweight or obesity.</p>

Consent (GLP-1 and GLP-1/GIP) Confirmation: *This is a required field. *I have read and understand the above information and I do consent and wish to move forward with this treatment plan *I have read the above information and I do not wish to continue *

Sorry, you're not currently eligible for GLP-1 medications

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