GLP-1 Pre-Assessment Form - Twelve28Rx

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GLP-1 Pre-Assessment Form

A short pre-screening form to confirm your eligibility for Semaglutide-based GLP-1 treatment. Once completed, you’ll continue to provider review for medical approval.

Step 1 of 6

16%

Are you 18 or older?

Yes

No

You must be 18 or older to proceed.

Have you used weight-loss medication before?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

This treatment is not safe during pregnancy or breastfeeding.

Do you have a history of thyroid cancer or MEN syndrome?

Yes

No

Unfortunately, you’re not eligible based on your medical history.

Are you currently using insulin or diabetes medication?

Yes

No

Please consult your provider before combining with this treatment.

Do you understand a licensed provider must approve treatment?

Yes

No

You must agree to provider review before continuing.

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