GLP-1 Patient Intake Form | Semaglutide & Tirzepatide Medical Weight Loss Clinic Template | PDF and Word

Streamline your patient onboarding process with this professional GLP-1 Patient Intake Form Template, designed for clinics and qualified healthcare practices offering Semaglutide, Tirzepatide, and GLP-1 medical weight management services.
This customizable patient intake form provides an organized way to collect important information including medical history, current medications, allergies, treatment goals, emergency contact information, and patient/provider signatures.

Perfect for medical weight loss clinics, med spas, wellness clinics, telehealth practices, and qualified healthcare providers, this template helps create a consistent and professional intake process for new GLP-1 patients.

WHAT’S INCLUDED
This GLP-1 Patient Intake Form includes sections for:
• Patient / Client Information
• Contact Information
• Medical History
• Current Health Conditions
• Diabetes History
• Thyroid History
• Gastrointestinal History
• Current Medications
• Medication Allergies
• Other Allergies
• Weight Management Information
• Treatment Goals
• Emergency Contact Information
• Patient / Client Signature
• Provider Signature
• Date Fields

Your purchase includes both PDF and Word document formats for convenient printing and customization.

PERFECT FOR
• Medical Weight Loss Clinics
• GLP-1 Clinics
• Semaglutide Programs
• Tirzepatide Programs
• Med Spas
• Medical Spas
• Wellness Clinics
• Telehealth Practices
• Nurse Practitioner Practices
• Physician Practices
• Weight Management Programs
• IV Hydration & Wellness Clinics
• Qualified Healthcare Providers
ORGANIZE YOUR GLP-1 PATIENT INTAKE PROCESS
A consistent intake process makes it easier to collect important patient information before a qualified healthcare provider evaluates the individual.
Use this template to help:

✓ Collect patient demographic information
✓ Document relevant medical history
✓ Record current medications
✓ Document medication and other allergies
✓ Identify patient treatment goals
✓ Collect emergency contact information
✓ Standardize new-patient paperwork
✓ Maintain organized intake documentation
✓ Obtain patient and provider signatures

DESIGNED FOR SEMAGLUTIDE & TIRZEPATIDE PROGRAMS
This form is designed for practices offering GLP-1 medical weight management services, including Semaglutide and Tirzepatide programs.
GLP-1 patient intake, Semaglutide intake, Tirzepatide intake, and medical weight loss forms are also commonly used search terms for this type of clinic paperwork, making this template easy to incorporate into a broader weight management documentation system.

CUSTOMIZABLE FOR YOUR PRACTICE
Personalize the Word document with your:
• Practice or clinic name
• Logo
• Contact information
• Patient information requirements
• Medical history questions
• Treatment program information
• Provider information
• Practice-specific procedures

Once customized, the form can be printed or incorporated into your existing patient onboarding and documentation workflow.

DIGITAL DOWNLOAD
This is a digital product. No physical item will be shipped.
Your purchase includes PDF and Word document formats.

After purchase, download your files, customize the applicable sections for your practice, and print or maintain completed forms according to your organization's documentation procedures.

IMPORTANT MEDICAL DISCLAIMER
This template is provided for general administrative and informational purposes only and does not constitute medical, legal, prescribing, regulatory, or compliance advice.
This form is not a clinical screening protocol, prescription, medical clearance, Good Faith Exam, or determination that an individual is eligible for Semaglutide, Tirzepatide, or any other GLP-1 medication.

Patient eligibility, contraindications, prescribing, informed consent, medication selection, dosing, monitoring, and treatment decisions must be determined by appropriately qualified healthcare professionals based on the individual patient's circumstances, current prescribing information, applicable clinical guidance, and applicable laws and regulations.

Purchasers are responsible for reviewing and customizing this template for their practice and applicable requirements.

Due to the nature of digital products, all sales are final.