Slimmher Intake Form

Full Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Date

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

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

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

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.

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.

Are you currently pregnant, breastfeeding, or planning to become pregnant?* This field is required.

Do you suffer from any allergies?* This field is required.

Are you currently receiving any medical treatment?* This field is required.

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

Are you currently taking any medication?* This field is required.Regular, prophylactic or short term dose

YESNO

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.

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.

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

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.

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

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

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

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.

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

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

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

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

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.

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

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

I have read and understand the Clinical Stability Acknowledgment. I agree to proceed without lab testing.* This field is required.

Yes

Please sign below to confirm.* This field is required.

If yes, please give details:

Do you have any significant/relevant past medical history?* This field is required.If yes please make practitioner aware

YESNO

If yes, please give details:

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.

Date* This field is required.Please enter today’s date

Date

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

Country

💸 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.

Consent to Medical Treatment & Risk Acknowledgment* This field is required. By signing below, I acknowledge and agree to the following: 1. Medical Treatment & Telehealth • I voluntarily consent to receive weight-loss treatment through Slimmher’s telehealth platform, which may include prescription GLP-1 medications such as semaglutide or tirzepatide. • I understand that this is a self-pay service and is not a substitute for full-spectrum primary care. • I confirm that I have provided complete and accurate information regarding my medical history, medications, and allergies. 2. Risks & Side Effects • I understand that all medications carry risks, which may include nausea, vomiting, diarrhea, constipation, abdominal pain, low blood sugar, dizziness, gallbladder issues, pancreatitis, or injection site reactions. • I accept that no treatment is without risk, and Slimmher and its providers cannot guarantee outcomes. 3. Labs & Testing • I understand that recent labs may be required for safe prescribing. • If I decline recommended lab work, I accept full responsibility for any health risks or undetected conditions that may result. • If I elect to purchase the Slimmher Lab Panel, I will receive an order to complete at a LabCorp location. 4. Refund & Eligibility Policy • All services are self-pay and non-refundable once approved and processed. • If I am found medically ineligible after provider review, a refund will be issued minus a $40 provider review fee. • Payment covers provider eligibility screening, chart review, and treatment plan setup. 5. Medication Eligibility • I understand that prescription medications will only be provided if medically appropriate. • Slimmher reserves the right to decline treatment if safety concerns exist. 6. Ongoing Care & Responsibility • I agree to follow all medical instructions, lab recommendations, and follow-up guidance from my Slimmher provider. • I agree to seek emergency or in-person medical care if I experience concerning symptoms. ⸻ ☑ I have read and understand the above. I consent to medical treatment, telehealth services, Slimmher’s refund policy, and acknowledge the risks and responsibilities outlined.

If you have ever taken Semaglutide or Tirzepatide, please provide the drug name and medication dose.

Choose your Slimmher Plan* This field is required.

My Bag

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®
$275.00Edit
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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®
$355.00Edit
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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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testing
$1.00Edit
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Slimmher Intake Form