Medical Weight loss Intake

Birthday*

Gender*

Perfferred method of contact*

Have you ever been diagnosed with any of the following? (check all that apply)*

Do you have a history of allergies or adverse reactions to medications ?*

Are you currently taking any medications including other-the-counter vitamins or supplements?*

Are you currently under the care of a physician for any chronic medical conditions?*

Do you have a history of any of the following? (check all that apply)*

Have you been pregnant or breast feeding in the last 12 months?*

what is your current weight loss goal? (check one)*

Have you previously used GLP-1 agonist like semaglutide before?*

Do you have any concerns about starting semaglutide?*

Do you understand that GLP-1 agonists like Semaglutide are part of a comprehensive weight loss program that includes diet, exercise, and lifestyle changes? *

I acknowledge that I have provided accurate and truthful information regarding my medical history and current health status*

I understand that I will undergo a full medical evaluation prior to starting treatment with Semaglutide *

I consent to the use of GLP-1 agonists as part of my weight loss program.*

I understand the potential risks and benefits associated with the use of Semaglutide agree to follow the prescribed treatment plan*