Semaglutide or Tirzepatide Form Questionnaire

"*" indicates required fields

Do you have a personal or family history of medullary thyroid carcinoma (MTC) ?*
Do you have a history of Acute or Chronic Pancreatitis?*
Do you have a history of severe gastrointestinal disease including gastroparesis?*
Do you have a personal or family history of Multiple Endocrine neoplasia syndrome type 2 (MEN 2) ?*
Do you have Diabetes Mellitus Type 1?*
Do you have a history of acute gallbladder disease?*
This field is for validation purposes and should be left unchanged.