Weight Loss Program Registration

Step 1 of 4

25%

Patient Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

ID (FRONT)

Max. file size: 300 MB.

ID (BACK)

Max. file size: 300 MB.

Product(Required)

Semaglutide

Tirzepatide

Liraglutide

Other Clinician-Prescribed Incretin-Based Medication

Date and Time(Required)

Medical History

Prior GLP-1 Use(Required)

Yes

Allergies (Including Any Adverse Reaction to GLP-1)

Allergies (if any)

Eligibility Risk Checklist (A checked “Yes” does not always mean treatment is prohibited, but contraindications and high-risk conditions require provider review and documentation)(Required)

Personal or family history of medullary thyroid carcinoma (MTC)

Known allergy or serious reaction to semaglutide, tirzepatide, liraglutide, or ingredients

Breastfeeding or planning to breastfeed

Gallstones, gallbladder disease, or prior cholecystitis

Liver disease or significant alcohol use concerns

Type 1 diabetes or history of diabetic ketoacidosis

Diabetic retinopathy, vision changes, or eye specialist care

Eating disorder, undernutrition, or inability to maintain adequate fluids/protein

Planned surgery, endoscopy, dental sedation, or anesthesia/deep sedation

Current use of another GLP-1/GIP medicine or duplicate semaglutide/tirzepatide product

None of these apply

Eligibility Risk Checklist(Required)

Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)Choice

Pregnant, trying to become pregnant, or unwilling to avoid pregnancy during therapy

History of pancreatitis or active severe abdominal pain

Kidney disease, dehydration risk, vomiting/diarrhea, or dialysis history

Severe GERD, severe gastroparesis, bowel obstruction, or ileus history

Type 2 diabetes using insulin, sulfonylurea, or other glucose-lowering medication

History of bariatric surgery or hypoglycemia episodes

Depression, suicidal thoughts, or recent significant mental health instability

Use of oral hormonal contraceptives, warfarin, narrow-therapeutic-index medications, or critical oral meds

Under age 18 or outside clinic protocol for this service

None of these apply

Medical Conditions

Consent

Consent Form

Consent(Required)

I confirm the Information is accurate and I agree with the consent forms

Weight Loss Program Registration

Rehoboth Urgent Care Weight Loss Program Registration

Patient Information

Medical History

Consent