• Patient Information

  • Are you the patient, completing this form for yourself?*

  • The patient must complete this form personally. Because this is a medical evaluation for a prescription, the person who will take the medication needs to fill out and sign their own health history. Please have the patient complete this form directly.

  • We're not able to treat patients in your state yet. AH WellnessMD currently serves patients located in New York, New Jersey, Connecticut, and Florida. Please do not continue with this form. We hope to serve your state in the future.

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  • Do you consent to receiving text messages about your prescription, including tracking and refill information?*
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  • Reproductive Health

  • What is the date of your last menstrual period? (if applicable)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you currently pregnant?*
  • Are you currently breastfeeding?*
  • Are you planning to become pregnant within the next 3 months?*

  • Lifestyle & Substance Use History

  • Do you use any kind of tobacco, or have you ever used tobacco products?*
  • Do you use any kind of illegal drugs, or have you ever used them?*
  • How often do you consume alcohol?*
  • Have you ever used anabolic steroids, testosterone/hormone products not prescribed to you, or other performance-enhancing or self-injected substances?*
  • Do you have any known allergy or sensitivity to injectable diluents (e.g., bacteriostatic water), rubber stoppers/latex, or prior injection-site reactions?*

  • Medical History — Contraindication Screening

  • Do you or any immediate family member (parent, sibling, or child) have a personal or family history of medullary thyroid carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN2)?*
  • Have you ever had a serious allergic reaction (e.g., swelling, hives, trouble breathing) to semaglutide, tirzepatide, liraglutide, or any other GLP-1/GIP medication?*
  • Do you have any other personal or family history of thyroid disease (e.g., thyroid nodules, Hashimoto's, hyperthyroidism)?*
  • Have you ever been diagnosed with pancreatitis (acute or chronic)?*
  • Have you ever been diagnosed with gastroparesis (delayed stomach emptying) or a bowel obstruction?*
  • Do you have a personal history of gallstones or gallbladder disease?*
  • Have you ever been diagnosed with an eating disorder (e.g., anorexia, bulimia, binge eating disorder)?*
  • Which of the following diagnosed medical conditions do you have? Check all that apply.*

  • Diabetes-Specific

  • Do you have diabetes or prediabetes?*
  • Have you ever had diabetic ketoacidosis (DKA)?*
  • Have you been diagnosed with diabetic retinopathy (diabetic eye disease)?*
  • Is your diabetic retinopathy currently being monitored or treated by an eye specialist?*

  • Mental Health Screening

  • Have you ever been diagnosed with depression, anxiety, or another mental health condition?*
  • Have you ever had thoughts of self-harm or suicide, or attempted suicide?*

  • If you are having thoughts of harming yourself right now, please call or text 988 (Suicide & Crisis Lifeline) or call 911. Help is available 24 hours a day. A board-certified medical practitioner will also review your answer and follow up with you directly.

  • Are you currently taking any psychiatric medications?*

  • Current Medications & Allergies

  • Do you currently take any medications?*
  • Are you currently taking any of the following? Check all that apply.*
  • Do you have any allergies to medications?*

  • Prior GLP-1 Therapy Experience

  • Have you ever used a GLP-1 or GIP receptor agonist medication before (e.g., semaglutide, tirzepatide, liraglutide, dulaglutide)?*
  • Have you ever used any peptide therapy before (e.g., BPC-157, TB-500, CJC-1295/Ipamorelin, Sermorelin, PT-141, Thymosin Alpha-1, NAD+, or others)?
  • Which of the following are you interested in and/or currently taking? Check all that apply.

  • Weight History

  • Surgical & Anesthesia History

  • Do you have any upcoming surgery or procedure requiring sedation or anesthesia in the next 4-6 weeks?*

  • Injection Acknowledgment

  • Please acknowledge the following statements (all boxes must be checked):*
  • Please affirm the following:*

  • Terms and Conditions

    I understand that any prescription medication products which are dispensed are intended only for the person for whom they were prescribed and I understand that sharing prescription medications is illegal. I attest that I am the patient and that the information I have provided is true, accurate, and complete. All information will be reviewed and confirmed between me and the medical provider before a prescription is issued.

    I understand that by filling out this form, a clinical provider may call me to verify the answers provided and will determine the suitability of the requested prescriptions for me based upon the information that I have provided. If deemed unsuitable by the provider due to safety concerns my request will be denied.

    I understand that a licensed clinical provider will send my prescriptions to a pharmacy for fulfillment. I understand and agree that all necessary information can be shared with pharmacy partners solely for order fulfillment purposes.

    Any dispute shall be resolved exclusively through private mediation and/or final and binding arbitration administered by the American Arbitration Association (AAA) with one arbitrator selected by mutual agreement. Mediation must be attempted before arbitration. Arbitration shall be conducted in East Northport, New York (Suffolk County). Amir Herman DO, PC will bear fifty percent of the filing fee. I waive any right to a jury trial. The arbitrator has exclusive authority over questions of interpretation, applicability, enforceability, or formation of this agreement. Either party may seek temporary injunctive relief in court to prevent irreparable harm pending arbitration.

  • Telehealth Informed Consent

    I consent to receive medical evaluation and care from a practitioner at AH WellnessMD through telehealth, using secure video, telephone, and electronic communications. I understand that a telehealth visit does not include an in-person physical examination, and that the practitioner may determine that telehealth is not appropriate for my care and refer me for an in-person evaluation. I understand that electronic communications carry some risk of technical failure or interruption despite reasonable security measures. I understand I may decline or withdraw from telehealth care at any time without affecting my right to future care. I confirm that I will be physically located in the state I listed above at the time of each visit.

  • COMPOUNDED / OFF-LABEL MEDICATION DISCLOSURE — I understand that if I am approved for treatment, a practitioner at AH WellnessMD may prescribe a compounded GLP-1 or GLP-1/GIP medication. I understand that compounded medications are not FDA-approved, and that the FDA does not review the safety, effectiveness, or quality of a compounded preparation before it is dispensed. I understand that my medication may be prescribed off-label — meaning the use, dose, schedule, or duration may differ from the FDA-approved labeling for a brand-name product. Off-label prescribing is lawful and based on my practitioner's clinical judgment; it is not FDA endorsement. I understand this may include being prescribed a weight-management medication at a BMI below the level described in the FDA-approved labeling, for modest weight loss, or in order to maintain my weight and prevent future weight gain, and that these are not FDA-approved uses. I understand possible risks include, but are not limited to, gastrointestinal side effects, pancreatitis, gallbladder disease, low blood sugar, kidney injury from dehydration, loss of muscle mass, delayed stomach emptying (which I must disclose before any surgery or sedation), and risks during pregnancy. These medications carry an FDA boxed warning: they caused thyroid C-cell tumors in animal studies, the risk in humans is unknown, and they must not be used by anyone with a personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2 (MEN2). I confirm I have accurately disclosed my personal and family thyroid history. I understand my specific medication, dose, and treatment plan will be determined by my practitioner and reviewed with me before I begin treatment; that no particular result has been promised to me; and that I will be asked to review and sign a more detailed consent form at that time. I may ask questions at any time before starting.

  • Congratulations — you may qualify!

    You will receive a phone call from a member of our team to review your information and discuss next steps.

  • Thank you — a board-certified medical practitioner will review your answers

    Based on your responses, a board-certified medical practitioner needs to review your health history before any next steps. Our team will contact you directly.
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