Review Your Information

Email *

Height (Inches) *

Weight (lbs) *

Blood Pressure:

SYSTOLIC mm Hg (upper number) *

DIASTOLIC mm Hg (lower number) *

Have you used Semaglutide/Tirzepatide in the past?

Have you ever experienced any complications or negative reactions from Semaglutide/Tirzepatide in the past?

If Yes, have you ever experienced any complications or negative reactions from Semaglutide/Tirzepatide in the past?

Are you currently taking any of the following medications? Select all that apply: *

Why are you requesting this medication? Select all symptoms that apply: *

If you do not have any, kindly type 'none' in the text box.

Past Medical History: *

Other - Family History: *

Do you have any allergies to medications? *

Amazing!

You're almost done! Now, let's do medications and supplements.

Please list all of your current prescriptions and over-the-counter medications and supplements:

Medication 1:

Name
Dose (m/g)
Times/Day

Medication 2:

Name
Dose (m/g)
Times/Day

Current Medications 3

Name
Dose (m/g)
Times/Day

Current Medications 4

Name
Dose (m/g)
Times/Day

For additional medications, please use this field to enter the details:

Informed Consent for Treatment via Telemedicine

Telemedicine services through Wittmer Rejuvenation Clinic are provided by medical providers contracted directly with (WRC). Our medical providers are licensed in all 50 states, and DC. By signing this form, you hereby consent to communicate with the Providers through telemedicine and receive diagnostic and treatment services via telemedicine. You further acknowledge the following:

I understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when they are located at a different site than the provider; and hereby consent to the Providers providing healthcare services to me via telemedicine.
I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
I acknowledge and understand that this telehealth consultation is for elective treatments and is not intended to diagnose, treat, or manage any medical illness or emergency condition. I confirm that I am not currently experiencing any symptoms of a serious medical condition that would require immediate or in-person medical attention.
I understand that health care delivery via telehealth is not analogous to an in-person delivery and assessment and that distorted photos, videos, or audio could lead to an incorrect diagnosis or conclusion and that there are potential risks to using telehealth, including interruptions, unauthorized access, and technical difficulties. If it is determined that the method of communication, videoconferencing equipment and/or connection is not adequate, I understand that my healthcare provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s); Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error
I understand that the laws that protect privacy and the confidentiality of medical
information also applies to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time. I may revoke my consent orally or in writing at any time by contacting [email protected]
I understand that a variety of alternative methods of medical care may be available to me and that I may choose one or more of these at any time.
I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that it is my duty to inform the Physician of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.
By placing your order, I am certifying that I have read or had this form explained to me, have had my questions answered to my satisfaction, and fully understand its contents. I have been offered a copy of this consent form. This document will become part of my medical record.

Do you agree with the Informed Consent for Treatment via Telemedicine? *

I agree.

MEDICATION INFORMED CONSENT FORM

(Tirzepatide)

1. Medication Overview

Tirzepatide are GLP-1 receptor agonists used for:

Type 2 Diabetes Management (Ozempic) Weight Management (Wegovy) Blood Sugar Control (Rybelsus)

These medications help regulate blood sugar, reduce appetite, and promote weight loss by affecting insulin secretion and slowing gastric emptying.

2. Benefits of Treatment

✅ Improved blood sugar control

✅ Potential weight loss

✅ Reduced risk of cardiovascular events in certain patients

✅ Lower risk of hypoglycemia compared to insulin

3. Potential Risks & Side Effects

By signing this form, I acknowledge that I have been informed of possible side effects, including but not limited to:

Common Side Effects:

🔸 Gastrointestinal Issues: Nausea, vomiting, diarrhea, constipation, bloating

🔸 Decreased Appetite

🔸 Injection Site Reactions (for injectable forms)

Serious Risks (Rare but Possible):

⚠️ Pancreatitis (severe stomach pain, nausea, vomiting)

⚠️ Gallbladder Issues (gallstones, pain in upper right abdomen)

⚠️ Thyroid Tumors or Cancer (Risk in animal studies—human risk unknown)

⚠️ Kidney Issues (Dehydration-related kidney damage)

⚠️ Severe Hypoglycemia (when used with other diabetes meds like insulin)🚨 DO NOT TAKE if you have:

Personal or family history of Medullary Thyroid Carcinoma (MTC)Multiple Endocrine Neoplasia Syndrome Type 2 (MEN2)Severe gastroparesis or digestive disordersHistory of pancreatitis

4. Treatment Plan & Responsibilities

By signing this form, I understand:

✔️ This medication is part of a comprehensive treatment plan, diet and exercise is recommended.

✔️ I should inject or take the medication as prescribed (weekly for injectables, daily for oral).

✔️ I should report any severe side effects immediately.

✔️ I may need regular blood tests to monitor my health.

✔️ This medication is not for pregnancy or breastfeeding; I must inform my provider if I plan to conceive.

5. Alternative Treatments

I understand that alternative options may include:

Other GLP-1 receptor agonists (e.g., Liraglutide)Dietary and lifestyle changesInsulin or oral diabetes medications

6. Patient Acknowledgment & Consent

I have reviewed the risks, benefits, and alternatives. I understand the information provided and consent to the use of:

Tirzepatide (Mounjaro)

I agree to follow the prescribed treatment plan for Tirzepatide and notify my provider of any concerns. *

I agree.

Ordering your Tirzepatide is fast, private, and hassle-free.

Simply complete a quick medical questionnaire to ensure our doctor has everything needed to approve your prescription, from there your medication will be discreetly shipped directly to your door—no pharmacy visits, no waiting rooms.