Patient Forms – finalfixrx.com

Patient Information

First Name*

Last Name*

Date of Birth*

Sex at Birth*

Email*

For appointment reminders and secure messages.

Mobile Phone*

Street Address*

City*

State*

ZIP Code*

Current Weight (lbs)*

Height (inches)

Primary Goal*

Have you tried GLP-1s or weight-loss medications before?

Have you had bariatric surgery in the past 18 months?

Are you currently taking any supplements? If so, please list them.

Have you had peptide therapy in the past?

Type 2 Diabetes?

Thyroid Cancer / MEN Syndrome?

Pancreatitis (past 6 months)?

Gallbladder issues (past 12 months)?

Kidney disease?

Pregnant or breastfeeding?

Currently on hormone therapy?

Allergies or medications (optional)

Exercise frequency

Preferred consultation type*

I consent to receive telehealth services.

I understand that a licensed provider will determine my eligibility.

Signature (type full name)*

Date*