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First Name
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Middle Initial
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Last Name
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DOB
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Phone Number
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Email Address
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Address (Street, City, State, and zip code)
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Height
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Weight
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Goal Weight
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Any known allergies?
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Current Medications
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Past Medical History
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Surgical History
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Are you 18 years or older?
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Do you have a history of pancreatitis?
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Pregnant or Breast feeding? (We recommend that you do not get pregnant or breast feed while taking this medication).
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Do you have any numbness/tingling, frequent urination, frequent thirst, or hunger?
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Unstable mental health, depression, or eating disorders?
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Personal or family history of medullary thyroid carcinoma or Endocrine Neoplasia Syndrome type 2?
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Do you drink more than 1 drink/day OR >7 days/week (woman) or men 2/day (>14/week)?
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Do you have a history of kidney concerns?
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We recommend being on birth control while receiving treatment to prevent pregnancy. If you are a female, do you understand.
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Are you currently taking Semaglutide or Tirzepatide? What is your dosage? How long have you been taking it?
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Do you visit your doctor yearly?
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Current movement/ activities
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Diet Weakness
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Do you think you fit the overweight/obesity category?
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Do you understand the consent and treatment plan?
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Do you agree to the consent form and all information listed above is truthful.
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I understand that my invoice has to be paid in full for prescription/refill to be submitted.
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I understand that while actively losing weight, I have to have a follow up every 12 weeks (maintenance 6 months).
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