Tirzepatide Patient Intake Form

About you

First name *

Last name *

Date of birth *

Sex at birth *

Email *

Phone *

Height (ft) *

Height (in) *

Current weight (lb) *

Goal weight (lb)

Shipping address

Where your medication will be delivered. Texas addresses only.

Street address *

Apartment, suite, or unit

City *

State *

ZIP *

I confirm I'm a Texas resident. Mito Fit Health is licensed to treat patients in Texas only.

GLP-1 history

Have you taken a GLP-1 medication before (semaglutide, tirzepatide, Ozempic, Wegovy, Mounjaro, Zepbound)? *

NoYes

If yes: which medication, dose, and why did you stop?

Health screening

Check anything that applies to you now or in the past. Your physician reviews these before prescribing, none of them automatically disqualify you.

Medullary thyroid carcinoma, in me or a blood relativeMultiple endocrine neoplasia type 2 (MEN 2)PancreatitisGallbladder disease or gallstonesGastroparesis or severe digestive diseaseKidney diseaseDiabetic retinopathyEating disorder, current or past

Diabetes status *

Pregnancy status (if applicable) *

I use oral hormonal birth control (the pill). Tirzepatide can reduce how well the pill is absorbed, especially when starting or increasing a dose, your physician will discuss backup contraception with you.

Medications & allergies

Current medications and supplements (include doses)

Drug allergies

Anything else your physician should know?

I understand this program uses compounded tirzepatide, which is prepared by a licensed pharmacy and is not FDA-approved or reviewed by the FDA for safety or efficacy.The information above is true and complete to the best of my knowledge, and I will tell my care team if anything changes. This form is not for medical emergencies, call 911 if you have an emergency.

Your answers go directly to your care team and are handled under our privacy policy.

Tirzepatide program intake

About you

Shipping address

GLP-1 history

Health screening

Medications & allergies

Consent