Retatrutide Consultation Form

First Name *

Last Name *

DOB *

Contact Phone # *

Gender *MaleFemale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Primary Care Provider Name *

Phone Number *

Drug: Retratrutide 30 mg

(Please select YES or NO for each)

Diet plan (such as Dash, diabetic, or other) *YesNo

Physical activity routine *YesNo

Metformin or another weight loss drug *YesNo

By signing below, I acknowledge that:

I understand the importance of following healthy lifestyle and diet habits to support long-term success.
I do not have a personal or family history of thyroid cancer, tumors, or related conditions.
I am participating in a consultation related to weight management.
I do not have a history of serious stomach or digestive conditions.
I do not have a personal or family history of pancreatitis.
I do not have a history of gallbladder disease.

Patient Signature *

Date *

I confirm that the following information was reviewed with me during the consultation:

Patient Signature *

Date *

I understand that I must provide my Stimulating Hormone (TSH) lab results to Better You Rx for this consultation.

Patient Signature *

Date *

By signing below, I confirm that all information I have provided in this form is true and complete to the best of my knowledge.

Patient Signature *

Date *