Weight Loss Intake Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number
*
Gender
*
Email Address
*
example@example.com
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Information
Insurance Carrier
*
Member ID
*
Subscriber's Name
*
Subscriber's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Group Number
*
Medical Information
Current Medications:
*
Medication Allergies:
*
Past Medical History of:
*
Confirm no Past Medical History of:
*
No personal or family history of Medullary Thyroid Carcinoma (MTC)
No history of Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
No known hypersensitivity to semaglutide or its ingredients
Additional Information
What are your weight loss goals?
*
Do you have any dietary restrictions?
*
Agreement and Signature
Agreement and Signature
*
I understand that the office visit will be billed to my insurance. I will be responsible for any co-pay or remaining balance. The Rx cannot be charged to insurance, and I must have a card on file. All payment will be collected upfront before the medication refill is complete.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Upload a picture of your photo ID (front and back):
*
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Upload a picture of your health insurance card (front and back):
*
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Submit
Submit
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