Semaglutide / Tirzepaptide Form

Please complete the consent form thoroughly and accurately, providing all necessary information. This ensures that our doctor can properly assess your eligibility for our weight loss program, including the use of semaglutide or tirzepatide. Your honesty and attention to detail will help us create the safest and most effective treatment plan for your needs.

First name

Last name

Email

Birthday

Gender

Address

Phone

PCP Information

What is your reason for Semaglutide/Tirzepatide?

Are you pregnant or planning to become pregnant in the future

Yes

No

Medical History

If there was anything you have not named on the list above please write it here.

List any medications you are currently taking.

Family medical history.

Date

Signature