Medical Weight Management and Peptide Interest Form

Patient Legal Name

First NameMiddle NameLast Name

Date of Birth

Date

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

ZIP Code

Height

Weight (lb)

Goal Weight (lb)

Patient Interest

Personal history of cancer

Family history of cancer

Currently pregnant, breastfeeding, or planning pregnancy

History of pancreatitis

History of gallbladder disease

History of gastroparesis, severe gastrointestinal disease, or bowel obstruction

History of kidney disease or increased dehydration risk

Diabetes therapy or increased risk of low blood sugar

History of diabetic retinopathy

Medication allergies or sensitivities

Any serious reaction to a GLP-1 or similar medication

Recent surgeries or emergency room visits

GLP-1 or peptide medications currently taking or previously taken, including dosage strength