Tirzepatide 30 Day Supply

First Name

Middle Initial

Last Name

DOB:

Sex at birth

Male Female

Weight in Lbs

Phone number

Email address

Home Address

Are you taking any medications or supplements?

Yes No

Do you have any medical allergies?

Yes No

How often do you consume alcohol?

Daily Weekly Monthly Occasionally Never

What is the primary reason that you are seeking weight loss treatment and what are your goals about weight control and management?

How often do you exercise?

Very little 2-3 days a week 3 or more days a week never

Have you had any mental health problems in the last 12 months? (i.e. anxiety, depression)

Yes No

Do you experience chronic pain?

Yes No

I attest that all information provided is true and correct.

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