Get Started

Weight Management Intake Form

Please read the patient information and fill out the form below.

  •  GLP-1 therapy is contraindicated in patients with a history of pancreatitis.
  •  GLP-1 therapy is contraindicated for use in patients with type 1 diabetes mellitus.
  • GLP-1 therapy is contraindicated for patients with a personal or family history of Medullary Thyroid Cancer or Type 2 Endocrine Neoplasia.

The most common side effects of GLP-1 include nausea, diarrhea, decreased appetite, vomiting, constipation, indigestion, headache, and stomach (abdominal) pain. These are not all the possible side effects of GLP-1 use.

👉🏽👉🏽 DO NOT USE/ CONTRAINDICATIONS TO GLP-1 THERAPY:

  •  Do not use GLP-1’s if you OR any of your family have ever had a type of thyroid cancer called medullary thyroid carcinoma (MTC) or Type 2 Endocrine Neoplasia.
  •  GLP-1 therapy is also contraindicated if you have a history of or are currently diagnosed with pancreatitis, kidney disease, or Type 1 diabetes.
  •  GLP-1’s are contraindicated in those who are pregnant, planning to become pregnant, or breastfeeding.
  •  GLP-1 therapy may reduce the effectiveness of your birth control pill. Consider non-oral contraception or add a barrier method after each dose escalation.
Scroll to Top

Refill Questionairre

Hi there! Looks like you are ready for a refill. To make sure we are treating you safely, please answer the following questions. Answering ALL of the questions will help us facilitate your refill faster than an incomplete check-in.
Consider the next dose if you have not lost weight, have been hungry before day 7 and tolerated your current dose without side effects. Again, decide based on your appetite suppression, and stay on the lowest effective dose as long as possible. More is not always necessarily better in this case. If requesting a retail medication please indicate the name and address of your pharmacy below
Call/Text Email Get Care Now