Integrative Weight Loss

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?*
Name*
This field is for validation purposes and should be left unchanged.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.