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Tirzepatide

Medical Questionnaire

Take just 3-5 minutes to answer a few important questions that will assist your physician in determining your tailored Compounded Tirzepatide weight management program.

Required to receive this special promotion: It's the last 4 digits of your friend's phone number.

Shipping State

Shipping State*

Height and Weight

ft. in.*

Date of Birth

What is your Date of Birth?

Date of Birth must be the same as on government ID. Minimum Age Requirement of 21 Years of Age or Older.

Gender

This information is important for medical purposes and helps us tailor your treatment plan appropriately.

Pregnancy

Your safety is our priority, and pregnancy needs special consideration. Why It's Important: Tirzepatide, like many medications, is not recommended for use during pregnancy.

Most Recent Menstrual Dates

When was your most recent menstrual start and end date?

(If no recent, specify below)

Understanding the dates of your last menstrual cycle is important for several reasons. First and foremost, it helps us ensure that you are not currently pregnant, as certain medications, including Tirzepatide, are not recommended during pregnancy due to potential risks to the developing fetus. The timing of your menstrual cycle can also provide insights into your overall reproductive health, including your hormonal balance and ovulatory patterns. This information is essential for determining the safest and most effective treatment plan for you

Tobacco

(tobacco or nicotine, including cigarettes, chewing tobacco, snuff, cigars, pipes, or vaping)

Cancer History

A history of cancer is important for us to know upfront. This ensures we choose the safest path forward for you.

Thyroid Cancer History

A history of cancer is important for us to know upfront. This ensures we choose the safest path forward for you.

Family Cancer History

A history of cancer is important for us to know upfront. This ensures we choose the safest path forward for you.

Diabetic Ketoacidosis

Allergies

Medications and Supplements

Surgical Procedures

Physician Care

Tirzepatide Use

Tirzepatide Dose

Last dose taken: Tirzepatide
*
How many weeks have you taken this dose?

Last Note

Please explain if there is anything else we haven't addressed or if you have any further questions, please add them here.

Side Effects

Please review the potential side effects of Tirzepatide and confirm your understanding of the risks and benefits before starting treatment:

I understand that common side effects of Tirzepatide may include: Nausea, vomiting, diarrhea, abdominal pain, and constipation.

I understand that serious side effects of Tirzepatide may include:

  • Hypoglycemia (low blood sugar):
    Especially if taken with other diabetes medications. Tirzepatide, when combined with insulin or sulfonylureas, increases the risk of low blood sugar. I understand that it is crucial to communicate my use of Tirzepatide with my doctor, who monitors my diabetes.

  • Pancreatitis:
    Severe stomach pain that does not go away, with or without vomiting, may indicate pancreatitis, which requires immediate medical attention.

  • Gallbladder Problems:
    Symptoms such as pain in the upper abdomen, fever, yellowing of the skin or eyes (jaundice), or clay-colored stools could signal gallbladder issues.

  • Kidney Issues:
    Tirzepatide may worsen kidney function, especially in patients with pre-existing kidney problems. Symptoms like reduced urine output, swelling in the feet or ankles, or fatigue should prompt immediate consultation with a healthcare provider.

  • Thyroid Tumors:
    There is a risk of thyroid C-cell tumors with Tirzepatide. This risk is higher in those with a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). Symptoms such as a lump or swelling in the neck, difficulty swallowing, or hoarseness should be reported to a doctor immediately.

Important Considerations

  • I understand that I should not use Tirzepatide if I have a personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

  • I understand that I must consult my general in-person healthcare provider before starting Tirzepatide, especially if I am pregnant, planning to become pregnant, or breastfeeding.

Action Steps:

  • I agree to and understand that I must contact my healthcare provider promptly if I experience any side effects or have concerns while taking Tirzepatide.

  • I agree to inform my primary care doctor about my Tirzepatide treatment, as well as any other doctors I am seeing. I will also get blood tests through my own doctor at their recommendation as needed. Please call or text us at 1-888-503-8488 if you have any questions or are unclear about anything.

By continuing and pressing NEXT you are agreeing to all term listed.

Contact Information

To avoid any discrepancies, please ensure that the information you enter matches your Government I.D.

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What's Next?

Confirm Health Status:

Complete the required health questionnaire to confirm health status, choose your product and purchase

Review & Approval Process:

24-Hour Priority Review: Your application undergoes a fast, priority review within 24 hours, from Monday to Friday

Direct Communication:

If we need more details, we'll reach out via text same day.

Fast Processing:

We send your prescription to the pharmacy within 24 hours on weekdays.

Support:

Text us at 1-888-503-8488 any time, or call between 7am to 7pm daily.

Prepare for Arrival:

Delivered 2-4 business days from today.

Quick Delivery:

Expect your medication to arrive in 3-6 business days. Look for a text message with your tracking information with-in 24 hours on weekdays.