GLP-1 Weight Loss Intake

Step 1 of 6

Patient Information

Please complete all fields accurately. This information is used to coordinate your GLP-1 weight loss care.

Personal Details

First Name *

Last Name *

Date of Birth *

Sex *

State *

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 2 of 6

Weight History

Help your physician understand your weight journey and past treatment history.

Weight History

Goal Weight (lbs)

Highest adult weight (lbs)

How long at current weight?

Previous weight loss attempts

Medication Preference

Which GLP-1 / weight loss medication are you interested in? (provider will make final recommendation)

Have you researched retatrutide? (triple agonist showing superior weight loss vs tirzepatide in trials)

Any specific concerns about injectable medications?

Prior GLP-1 Experience

Have you used a GLP-1 medication before?

Step 6 of 6

Informed Consent

Please read carefully. Your electronic signature is legally binding under Florida Statute §668.50.

Consent for GLP-1 Therapy

Nature of Treatment

I am consenting to receive GLP-1 receptor agonist therapy (semaglutide or tirzepatide) prescribed by a licensed Florida physician through Lavena Health.

Potential Benefits

Significant and sustained weight loss
Improved blood sugar control
Reduced cardiovascular risk
Improved energy, mobility, and quality of life

Risks & Side Effects

Nausea, vomiting, diarrhea — most common, typically improve over time
Risk of pancreatitis — seek care if severe abdominal pain occurs
Contraindicated in personal or family history of medullary thyroid carcinoma (MTC)
Possible muscle loss if protein intake is inadequate

Direct-Pay & Truthfulness

I certify all information is truthful. I understand Lavena Health is a cash-pay clinic and no insurance is billed. I may withdraw consent at any time.

Identity Verification

Why we ask: Florida law and federal telehealth regulations require that prescribing physicians verify patient identity before issuing prescriptions. Your attestation below satisfies this requirement for your initial intake. A government-issued photo ID may be requested at or before your first consultation.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I have read and understood the risks and benefits of GLP-1 therapy.

I do not have a personal or family history of medullary thyroid carcinoma (MTC) or MEN2.

I agree to complete required baseline labs and follow-up monitoring.

I confirm I am 18 or older and voluntarily consent to GLP-1 therapy through Lavena Health.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your name and submitting, you provide a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Patient Information

Weight History

Medical History

Medications & Labs

Goals & Lifestyle

Informed Consent