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Semaglutide Health Assessment Form

Before we can ship your medication to you, we need to collect a few pieces of information about your health to make sure our compounded medicine is right for you.

What is your gender assigned at birth?(Required)

Male

Female

What is your date of birth?(Required)

Month

Day

Year

Current height in feet:(Required)

Current height in inches(Required)

Please enter a number from 0 to 11.

Current weight in pounds:(Required)

Current BMI:

What is your goal weight?(Required)

Do you have any of the following conditions related to your weight?(Required)

Diabetes, prediabetes, or insulin resistance

Polycystic ovarian syndrome (PCOS)

Depression/anxiety

Sleep apnea

Joint pain

Other weight related condition

None of the above

Please list your other weight-related condition(s):(Required)

Have you previously taken any weight loss drug?(Required)

Yes

Please list any weight loss drugs you have previously taken:(Required)

Are you currently using any of the following medications?(Required)

Semaglutide

Tirzepatide

Wegovy

Ozempic

Mounjaro

Zepbound

Liraglutide

Trulicity

Victoza

Saxenda

None of the above

Are you taking any of the following diabetic medications?

Insulin

Sulfonylurea

None of the above

Are you taking any other medications/supplements?(Required)

Yes

Please list all other medications/supplements you are currently taking.(Required)

Name - Dosage

Do you have any known allergies to medication?(Required)

Yes

Please list any known allergies to medication.(Required)

Example: Rybellsus

Do you have any other medical conditions not discussed above?(Required)

Yes

Please list any other medical conditions.(Required)

Do you or anyone in your family have multiple endocrine syndrome type 2 (MEN2)?(Required)

Yes

Have you or anyone in your family had medullary thyroid cancer?(Required)

Yes

Have you ever had gallbladder disease or pancreatitis?(Required)

Yes

Are you pregnant or planning on becoming pregnant?(Required)

Yes

Note: Males are also expected to be off Semaglutide during family planning and should select Yes if they are trying to get their partner pregnant.

Are you breastfeeding?(Required)

Yes

When was the last time you saw your primary care physician?(Required)

Month

Day

Year

When was the last time you had lab work drawn?(Required)

Month

Day

Year

Disclaimer & Agreement

Consent(Required)

I have read and understand the information below.(Required)

Medical weight loss is a supplement to a healthy diet and exercise program. Weight loss beyond 2 lbs per week can present health risks. Consult your physician before making any changes.

Consent(Required)

I have read and understand the information below.(Required)

I agree to only receiving GLP-1 treatment from one provider/pharmacy at a time. I will follow my provider’s instructions exactly as written.

Because you live in , we are required to have your driver's license on file. Please use the fields below to submit your license photos.

Front of license:(Required)

Accepted file types: jpeg, jpg, png, webp, Max. file size: 10 MB.

Back of license:(Required)

Accepted file types: jpeg, jpg, png, webp, Max. file size: 10 MB.

Congratulations!

You've been pre-approved for Semaglutide.

Your medical information is being reviewed by one of our partnered providers. If they have a question about your assessment, they will reach out to you via our secure messaging system on the My Account page.

-Dr. Reed Hogan III
Head of Provider Team

Semaglutide Health Assessment Form

Disclaimer & Agreement

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