Retatrutide Consultation Form

Retratrutide Dosage Selection

Drug: Retratrutide 30 mg

PREVIOUS WEIGHT MANAGEMENT METHODS

(Please select YES or NO for each)

CONSULTATION REVIEW CONFIRMATION

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.

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

• General Retatrutide information
• Usage and handling guidance
• Healthy lifestyle and nutrition recommendations

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

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