GLP-1 Intake Form - Serenity Glow & Wellness

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Getting Started

Tell us about yourself

This information helps our clinical team prepare for your consultation and confirm telehealth eligibility in your state.

FIRST NAME*

LAST NAME*

Date of Birth*

MM slash DD slash YYYY

SEX ASSIGNED AT BIRTH*

EMAIL ADDRESS*

PHONE NUMBER*

STATE OF RESIDENCE*

Eligibility Screening

Your body metrics

GLP-1 therapy requires a BMI of 30 or above, or 27 or above with a qualifying health condition. We'll calculate yours automatically.

HEIGHT - FEET*

HEIGHT - INCHES*

CURRENT WEIGHT (LBS)*

BMI

Underweight GLP-1 therapy may not be appropriate. Our team will review.

Normal weight GLP-1 eligibility requires BMI ≥27 with a qualifying condition.

Overweight May qualify with a documented comorbidity (PCOS, hypertension, etc.)

Obese - Class I Meets standard GLP-1 eligibility criteria.

Obese - Class II/III Meets GLP-1 eligibility criteria.

GOAL WEIGHT (LBS)*

WHICH BEST DESCRIBES YOUR PRIMARY GOAL?*

WEIGHT LOSS & METABOLIC HEALTH

PCOS MANAGEMENT

HORMONAL BALANCE & WELLNESS

FERTILITY SUPPORT

Medical History

Your health history

Please answer honestly — this helps our clinical team determine the safest protocol for you. Some conditions are contraindications to GLP-1 therapy.

DO YOU HAVE A PERSONAL OR FAMILY HISTORY OF MEDULLARY THYROID CARCINOMA (MTC) OR MULTIPLE ENDOCRINE NEOPLASIA TYPE 2 (MEN2)?*

YES OR UNSURE

⚠️ Based on your responses, GLP-1 therapy may not be appropriate for you. Our clinical team will review your intake and reach out with personalized guidance.

HAVE YOU EVER BEEN DIAGNOSED WITH PANCREATITIS?*

YES

⚠️ Based on your responses, GLP-1 therapy may not be appropriate for you. Our clinical team will review your intake and reach out with personalized guidance.

DO YOU HAVE A HISTORY OF GALLBLADDER DISEASE OR GALLSTONES?*

YES

DO YOU HAVE KIDNEY OR LIVER DISEASE?*

YES

DO YOU HAVE GASTROPARESIS OR SIGNIFICANT GASTROINTESTINAL (GI) MOTILITY ISSUES?*

YES

WHICH OF THE FOLLOWING HAVE YOU BEEN DIAGNOSED WITH?

HIGH BLOOD PRESSURE

TYPE 2 DIABETES / PREDIABETES

PCOS

SLEEP APNEA

HIGH CHOLESTEROL / LIPIDS

NONE OF THE ABOVE

Current Medications

What are you currently taking?

This helps us screen for interactions and personalize your protocol safely.

ARE YOU CURRENTLY TAKING ANY DIABETES OR WEIGHT LOSS MEDICATIONS?*

YES

ARE YOU CURRENTLY TAKING INSULIN?*

YES

ARE YOU CURRENTLY TAKING ORAL CONTRACEPTIVES (BIRTH CONTROL PILLS)?*

YES

PLEASE LIST ALL CURRENT MEDICATIONS, SUPPLEMENTS, AND DOSAGES.

DO YOU HAVE ANY KNOWN DRUG ALLERGIES?

Reproductive & Hormonal Health

Your cycle & fertility

This section is unique to our practice. We integrate GLP-1 therapy with your full hormonal picture — fertility, cycle health, and reproductive goals all matter here.

ARE YOU CURRENTLY PREGNANT OR BREASTFEEDING?*

YES

GLP-1 medications are not recommended during pregnancy or breastfeeding. Our team will follow up to discuss safe alternatives and support options.

ARE YOU ACTIVELY TRYING TO CONCEIVE (TTC)?*

YES - NATURALLY

YES - IUI

YES - IVF / STIMS

HAVE YOU BEEN DIAGNOSED WITH (PCOS)?*

YES

SUSPECTED / UNDIAGNOSED

NOT SURE

ARE YOU CURRENTLY USING ANY FORM OF HORMONAL CONTRACEPTION?*

NONE

ORAL PILL

HORMONAL IUD

COPPER IUD

IMPLANT / SHOT

OTHER

DATE OF LAST MENSTRUAL PERIOD

MM slash DD slash YYYY

TYPICAL CYCLE LENGTH

PREVIOUS WEIGHT LOSS ATTEMPTS — WHAT HAVE YOU TRIED?

Almost Done

Review & consent

Please read and acknowledge each item below before submitting your intake form.

By submitting this form you are not yet enrolled in a program. A member of our clinical team will review your intake and reach out within 1–2 business days.

Consent*

I understand that compounded GLP-1 medications are not FDA-approved finished drug products and are prepared by licensed compounding pharmacies for patients with documented clinical need.

I confirm that I am not currently pregnant or breastfeeding, and I am not planning to become pregnant within the next 2 months.

I agree to monthly check-ins with the Serenity Glow & Wellness clinical team and to report any significant side effects promptly.

I understand that my information will be reviewed by a licensed provider and that a prescription is not guaranteed. Eligibility is determined at the clinical team's discretion.

I have provided accurate and complete information to the best of my knowledge. I understand that withholding relevant medical history may affect my safety and care.