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.
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