Launch pricing ends soon — save 20% on every template with code CLINIC20
$97.00
A complete, attorney-reviewed screening and eligibility form for GLP-1 weight-loss programs. It captures BMI, medical history, contraindications and eligibility criteria so you can document that each patient was properly screened before treatment.
Weight-loss clinics, med spas and telehealth programs offering GLP-1 therapy that need to document eligibility and contraindication screening before a prescription. Pairs directly with the GLP-1 and tirzepatide consent forms.
Skipping documented screening is one of the biggest compliance gaps in GLP-1 programs. Free intake forms don’t capture the GLP-1-specific contraindications this one does.
Download the editable Word file, complete it at intake, and keep it on file with the matching consent. PDF included.
Use this form to capture BMI, history, medications and the GLP-1-specific contraindications, then record the provider’s eligibility determination.
Thyroid / MEN2 history, pancreatitis, pregnancy and breastfeeding, and relevant medication interactions, among others.
Yes — screen with this form first, then obtain consent with the GLP-1 / semaglutide consent.
Yes, it works for in-person and telehealth programs.
