Slimmher Intake Form

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Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
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Contact number* This field is required.By providing your phone number, you consent to receive medication details, health-related updates, and other Slimmher communications.
Area Code
Phone Number
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E-mail* This field is required.By providing your email address, you consent to receive medication details, health-related updates, and other Slimmher communications.
example@example.com
Confirm Email
5
What is your current weight loss goal?* This field is required.
Lose 1-20 pounds
Lose 51+ pounds
Lose 21-50 pounds
Not sure yet
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What kind of results or changes are you hoping for with Slimmher?* This field is required.I want to...
Lose weight in a way that feels sustainable.
Improve my overall physical health and wellbeing.
Feel more confident in my body and appearance.
Boost my energy for the things I love doing.
I have a different goal not listed here.
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We use your BMI to personalize your Slimmher weight loss plan and determine eligibility for GLP-1 medications like semaglutide. Don't worry - this won't be shared with anyone. * This field is required.Lets find your starting point! A BMI under 25 is not recommended for weight-loss medications.
8
Are you currently pregnant, breastfeeding, or planning to become pregnant?* This field is required.
Please Select
Please Select
Yes
No
9
Are you currently receiving any medical treatment?* This field is required.
Please Select
Yes
No
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If you are receiving medical treatment, please explain below. If you are not receiving medical treatment, type N/A.* This field is required.Medical treatment explanation
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Are you currently taking any medication?* This field is required.Regular, prophylactic or short term dose
YESNO
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Please list medication below along with dosage. If you are not taking any medication, type N/A.* This field is required.Please list medication below.
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Have you seen your primary care provider in the past 12 months?* This field is required.While Slimmher provides medically guided weight loss support, we do not serve as a substitute for full- spectrum primary care.
Please Select
Please Select
Yes
No
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Do you currently have- or have you ever been diagnosed with any of the following heart related conditions?* This field is required.Some conditions may affect how your body responds to GLP-1 medications. This helps us keep your care as safe and personalized as possible. Please select all that apply .
High blood pressure (hypertension)
Heart attack (myocardial infarction)
Stroke or TIA (mini-stroke)
Heart Failure or congestive heart failure (CHF)
Arrhythmia or irregular heartbeat (e.g. atrial fibrillation)
Coronary artery disease (CAD)
Cardiomyopathy
Heart valve disorder
Tachycardia (episodes of rapid heart beat)
Prolonged QT interval
Vascular disease
Other heart rhythm issues or ECG abnormalities
None of the above
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What was your most recent blood pressure reading in the last 12 months? * This field is required.
Less than 140/90
Greater than 140/90
I haven't measured it in the last 12 months.
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Have you ever been diagnosed with any of the following hormone, kidney, or liver conditions? * This field is required.These conditions can affect how your body responds to treatment. Please select all that apply so we can ensure your care is safe and appropriate. GLP-1's are not recommended for people with a history of MEN2 (Multiple Endocrine Neoplasia Type 2)
Multiple Endocrine Neoplasia syndrome type 2 (MEN2)
Chronic kidney disease (CKD)
Fatty liver disease (NAFLD or NASH)
Kidney stones
Liver cirrhosis or end-stage liver disease
Hypothyroidism (underactive thyroid)
Hyperthyroidism (overactive thyroid)
Grave's disease
Other thyroid issues
Polycystic Ovarian Syndrome (PCOS)
Syndrome of inappropriate antidiuretic hormone (SIADH)
None of the above
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Have you been diagnosed with any of the following?* This field is required.Knowing where you are in your journey helps us choose the safest and most effective treatment for your body. Please select the option that best applies.
Diabetes that requires insulin
Diabetes that does not require insulin
Prediabetes or insulin resistance
None of these conditions apply to me
Other
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Have you or a family member ever been diagnosed with thyroid cancer?* This field is required.Some types of thyroid cancer, especially medullary thyroid cancer are linked to genetic conditions that may increase your risk. Please select all that apply.
Yes, papillary thyroid cancer
Yes, medullary thyroid cancer (MTC)
Yes, follicular thyroid cancer
Yes, anaplastic thyroid cancer
Yes, but I am not sure what type
No
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Do you currently have or have a history of any of the following GI conditions or procedures?* This field is required.Some gastrointestinal conditions may affect how your body responds to GLP-1 medications. Please select all that apply so we can make sure your care is safe and effective.
Bariatric surgery
Delayed gastric emptying or gastroparesis
Gallstones or gallbladder disease
GERD/Acid reflux
No, I do not have a history of any of these conditions or procedures.
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Do you have a history of any of the following mental health conditions?* This field is required.Mental health plays an important role in your overall wellness. Some conditions may require extra care when starting GLP-1 medications. Your responses are private and help us personalize your treatment safely and respectfully. Please select all that apply.
Anxiety
Borderline personality disorder
Bipolar Disorder
Depression
History of suicidal thoughts or suicide attempt
Panic disorder
Schizophrenia
No, I have not been diagnosed with any of these conditions
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Have you ever been diagnosed with any of the following conditions?* This field is required.These conditions may affect how your body responds to treatment.
Chronic candidiasis (recurrent yeast or fungal infections)
Eating disorder (past or current)
Glaucoma
Gout
Heavy alcohol use (more than 15-20 drinks per week)
Hirsutism (excess body hair in women)
Lymphedema or chronic lower extremity swelling (not caused by heart, kidney, or liver disease)
Metabolic syndrome
Obstructive sleep apnea
Migraine headaches
Opioid use disorder
No, I have not been diagnosed with any of these conditions
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Do you currently take any of the following medications?* This field is required.
A GLP-1 medication (e.g. semaglutide [Ozempic/Wegovy], tirzepatide [Mounjaro/Zepbound], liraglutide [Saxenda/Victoza] dulaglutide [Trulicity])
A sulfonylurea (e.g., glipizide [Glucotrol], glimepiride [Amaryl])
Insulin
Warfarin (e.g., Jantoven, Coumadin)
A meglitinide (e.g. repaglinide or nateglinide)
A diuretic (e.g. furosemide [Lasix] bumetanide [Bumex], hydrochlorothiazide [HCTZ])
A Monoamine Oxidase Inhibitor (MAOI) (e.g., phenelzine [Nardil], selegiline [Emsam])
An opioid (e.g., oxycodone [Oxycontin], hydrocodone [Norco/Vicodin], methadone, Suboxone, Dilaudid)
I am not currently taking any of these medications
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Which of the following weight loss methods have you tried in the past? * This field is required.Select all that apply.
Exercise
Specialized diet (Paleo, Atkins, Keto, etc.)
Low-calorie diet
Meal replacements
Commercial weight loss plan (e.g., Weight Watchers, Jenny Craig)
Over the counter weight loss supplements
Prescription weight loss medication
Other
None of the above
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Is there anything else you'd like your Slimmher provider to know about your health?Please include other concerns, allergies, symptoms, or details about the conditions you have already shared. Examples: recent lab results, hormonal imbalances (like PCOS or thyroid issues), menstrual changes, past surgeries, sleep problems, digestion concerns, drug allergies, or anything else that you think is important.
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Do you have recent lab results you'd like to upload (from last 6 months)?If yes, please upload below.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Don’t have recent labs? We’ve got you covered! Our Slimmher weight loss panel includes key tests to help us safely personalize your care. For $100, we’ll send you a lab order by email that can be used at any LapCorp location near you.* This field is required.Included in your lab panel: Thyroid (TSH), Kidney function (BUN, Creatinine), Liver enzymes (ALT, AST), Blood sugar and A1C.
Yes, I’d like to order the lab panel (+ $100)
No, I’d prefer to proceed without labs
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Health Status and Lab Testing Acknowledgment

I confirm that I believe I am currently in stable health and am not experiencing symptoms that require further evaluation, such as dizziness, swelling, fatigue, or unexplained weight changes.

I understand that laboratory testing is recommended prior to starting weight loss medication.

I acknowledge that Slimmher and its providers will rely solely on the information I have provided in my intake form to assess my suitability for treatment.

I accept full responsibility for any adverse effects or undetected health conditions that may result from my decision to decline recommended lab work.

I agree to seek medical care from a licensed provider if I develop any concerning symptoms in the future.
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I have read and understand the Clinical Stability Acknowledgment. I agree to proceed without lab testing.* This field is required.
Yes
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Please sign below to confirm.* This field is required.
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Do you suffer from any allergies?* This field is required.
Please Select
Please Select
Yes
No
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If yes, please give details:
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Do you have any significant/relevant past medical history?* This field is required.If yes please make practitioner aware
YESNO
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If yes, please give details:
Huge
Large
Normal
Small
Ok
Ok
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Signature* This field is required.Consent to Treatment & Use of Telehealth Services By signing below, I voluntarily consent to receive weight loss treatment through Slimmhers telehealth platform. I understand that: • My treatment may include the use of prescription weight loss medications. • I have truthfully completed the medical intake form to the best of my knowledge. • I may be contacted if additional medical information is needed before a provider can approve treatment. • Telehealth services may not be a substitute for in-person care, and I am encouraged to maintain a relationship with a primary care provider. • I understand the potential risks and side effects of prescribed medications, which may include nausea, constipation, low blood sugar, allergic reactions, or other adverse effects. • I understand that Slimmher reserves the right to decline treatment if medically inappropriate. ☐ I have read and understand the above. I consent to treatment and the use of telehealth services.
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Date* This field is required.Please enter today’s date
Date
Month
Day
Year
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Address* This field is required.Please enter your shipping address This is where your medication will be delivered. PO Boxes are not accepted.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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💸 Refund & Eligibility Policy* This field is required.Payment and Service Policy Your payment covers a comprehensive provider review, medical eligibility screening, and care setup. Please note: If you are found medically ineligible for treatment, a refund will be issued minus a $40 provider review fee. All services are self-pay and non-refundable once approved and processed. You will receive follow-up instructions from a Slimmher provider within 1–2 business days.
I have read and agree to Slimmher’s Refund & Eligibility Policy.
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What are my weight-loss options?

At Slimmher, we offer two highly effective weight loss treatments: Semaglutide and Tirzepatide. Both are FDA-approved GLP-1–based therapies that help regulate appetite, improve blood sugar balance, and support long-term fat loss. The key difference lies in how they work — and how your body responds.

💉 Semaglutide

(Brand examples: Ozempic® / Wegovy®)
• Works on the GLP-1 hormone to increase feelings of fullness and reduce appetite
• Often leads to steady, sustainable weight loss over time
• May be ideal for those newer to weight loss medications or seeking a gradual approach

💉 Tirzepatide

(Brand examples: Mounjaro® / Zepbound®)
• Works on two hormones — GLP-1 and GIP — for more aggressive appetite and insulin control
• May produce faster weight loss and improved metabolic results
• Often preferred by patients with insulin resistance, PCOS, or stubborn weight plateaus

Your Slimmher provider will carefully review your health history, labs, and goals to ensure the option you select is both clinically appropriate and safe.
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Consent to Medical Treatment & Risk Acknowledgment* This field is required.Consent and Acknowledgment for Slimmher Medical Treatment By submitting this form and initiating medical treatment through Slimmher, I confirm the following: I voluntarily consent to receive treatment with prescription weight loss medications, including but not limited to Semaglutide and Tirzepatide, as determined appropriate by my provider. I understand that all medications carry risks, which may include but are not limited to: nausea, vomiting, constipation, diarrhea, headache, dizziness, fatigue, low blood sugar, allergic reactions, pancreatitis, gallbladder issues, or injection site reactions. I confirm that I have disclosed all relevant medical conditions, medications, allergies, and history to the best of my knowledge. I acknowledge that my provider will make treatment decisions based on the information I have provided, and that Slimmher is not liable for adverse outcomes arising from omissions or inaccurate information submitted by me. I understand that this is a telehealth-based, self-pay service, and that treatment is not guaranteed. If I am deemed ineligible, I may be refunded minus a provider review fee. I understand that while my provider will use their best clinical judgment, no medical treatment is without risk, and I release Slimmher, its affiliates, providers, and agents from liability for any adverse effects, injury, or complications that may arise from treatment, to the fullest extent allowed by law. I acknowledge that prescription medications are only provided when deemed medically appropriate, and I agree to follow all instructions, lab recommendations, and follow-up guidance provided by my Slimmher provider.
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Choose your Slimmher Plan* This field is required.
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ORDER SUMMARY
Total costUSD
Semaglutide Treatment VisitIncludes full provider review, prescription eligibility screening, and wellness support. Semaglutide works by helping regulate appetite, increase fullness, and support blood sugar balance. Brand examples include Ozempic® and Wegovy®
$299.00Edit
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TirzepatideIncludes comprehensive provider review, eligibility check, and ongoing care.Tirzepatide targets both appetite and insulin resistance to support sustainable fat loss.Brand examples include Mounjaro® and Zepbound®
$375.00Edit
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Slimmher Lab PanelPerfect if you haven’t had recent labs. This panel checks thyroid, kidney, liver function, A1C, and glucose — key markers for safe medication use. Your order will be emailed and can be completed at any LabCorp location.
$100.00Edit
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Total cost $0.00
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