GLP-1 Receptor Agonist Program Intake & Consent Form (Template)

Streamline Your GLP-1 Therapy Onboarding Process with This Comprehensive Intake & Consent Form
 
This professionally designed GLP-1 Receptor Agonist Program Intake & Consent Form is a ready-to-use template for healthcare providers offering Semaglutide, Liraglutide, Dulaglutide, Tirzepatide, and other GLP-1 medications. Designed to ensure efficient patient intake, informed consent, and regulatory compliance, this form covers all necessary medical history, contraindications, potential risks, and patient responsibilities in one structured document.
 
Key Features:
✅ Comprehensive Medical History Section – Includes checklists for conditions like diabetes, hypertension, obesity, PCOS, thyroid disorders, and more.
✅ Medication & Allergy Screening – Ensures safe prescribing with thorough documentation of current medications and allergies.
✅ Contraindications & Risk Assessment – Flags key conditions that may exclude patients from GLP-1 therapy.
✅ Potential Risks & Side Effects – Clearly outlines common and serious side effects to ensure informed consent.
✅ Dosing, Monitoring & Lifestyle Guidance – Educates patients on best practices to optimize treatment success.
✅ Legally Compliant Consent Section – Includes patient acknowledgment and signature fields for documented approval.
✅ Provider Notes Section – Allows for easy documentation of baseline metrics such as weight, BMI, A1c, and lab results.
 
Who Is This For?
✔ Physicians, Nurse Practitioners, and Physician Assistants prescribing GLP-1 medications.
✔ Weight Management Clinics & Endocrinology Practices offering medical weight loss programs.
✔ Telehealth & Concierge Medicine Providers looking for a digital-friendly intake solution.
 
Why Use This Template?
🔹 Saves Time – Eliminates the need to create an intake form from scratch.
🔹 Ensures Compliance – Covers all necessary legal and medical consent requirements.
🔹 Enhances Patient Safety – Standardizes screening for contraindications and risk factors.
🔹 Improves Efficiency – Helps providers streamline documentation and follow-up processes.
 
📩 Download Now to optimize your GLP-1 patient intake workflow and enhance the efficiency of your weight management program!