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Semaglutide & Tirzepatide

a.k.a Ozempic & Mounjaro (GLP -1 Agonist)

Compatibility Form & Waiver

*We need at least your email address to continue...

Are you sure your birthday is January 3, 2023? Please confirm your birthday below:


*Age is populated using your Birthday.

First, click select the year at the top right corner and then use the arrows to select the month before you choose the day.




Weight History

When did you become overweight?
Did you ever gain more than 20 pounds in less than 3 months?

How much did you weigh...

Triggers for your weight gain (check all that apply):
Previous weight-loss programs (check all that apply):
Have you ever taken any of these medications? (check all that apply):
Did it work?

Medical History

Do you exercise?
Are you pregnant or are you trying to become pregnant?
Do you feel rested in the morning?
Please check if you are or have had any of the following (check all that apply):
Do you still have cancer?
Have you ever been diagnosed with an eating disorder?
Is it anorexia?
Are you currently taking diuretics?
Past surgical history (check all that apply):
Are you currently taking any medication?
Do you have history of allergy to semaglutide or other glp-1?
Do you have allergies?

Patient Waiver Acknowledgement and Signature

Patient Signature

Patient Full Name

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