Name *

First Name

Last Name

Are you 18 years of age or older? *

Yes

No

Are you currently pregnant or nursing? *

Yes

No

Do you have a personal or family history of medullary thyroid cancer?

Yes

No

Do you have a personal history of pancreatitis?

Yes

No

By signing below I acknowledge that any prescribed medication to aid in weight management may not be covered by my insurance, and agree that I am willing to pay for the medication out of pocket.

By checking this box, I agree to use electronic records and signatures and I acknowledge that I have read the related consumer disclosure.

Date

MM

DD

YYYY