GLP-1 Intake Form - Serenity Glow & Wellness

Step 1 of 6

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*

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

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?

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.

Tell us about yourself

Your body metrics

Your health history

What are you currently taking?

Your cycle & fertility

Review & consent