4299 San Felipe St. Suite 100 Houston Tx 77027

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Patient Information

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Consent Forms

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In-Clinic Appointment

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Completed

Full Name *

Email *

Phone

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Address

Street Address

City

State

Postal code

Gender *

What is your date of birth? *

Height (ft) *

Height (Inches) *

Weight *

What is your goal weight? *

Have you use Tirzepatide or Semaglutide before? *

YES

NO

When was your last injection? *

How many units did you inject? *

What was the dose? *

How long have you been on GLP1s? *

How much weight have you lost in total? (kg) *

Any Allergies to Medication

Yes

No

Check Medical Conditions that Apply to you:

What medications are you currently taking? Please list them below.

Safety Screening

Pregnant, planning pregnancy, or breastfeeding? *

Yes

No

Allergies to semaglutide, tirzepatide, or similar medications? *

Yes

No

History of kidney disease, liver disease, or heart failure? *

Yes

No

Unexplained weight loss, abdominal pain, or digestive issues? *

Yes

No

Do you have any of the conditions above? *

Yes

No

01

Patient Information

02

Consent Forms

03

In-Clinic Appointment

03

Completed

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