BetterHumanz

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Basic Information

Please provide your contact details.

Full Name*

Date of Birth*

Age*

Phone Number*

Email Address*

Address*

City*

State / Region*

Zip / Postal Code*

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Goals & Reason for Inquiry

Help us understand your objectives.

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Prior Experience

Tell us about any previous medication experience.

Have you ever used Retatrutide before?

YesNo

Have you used any GLP-1 or weight-loss medication before?

YesNo

If yes, which ones?

How did you respond to them?

Did you experience side effects?

Are you currently taking any fat-loss medication, GLP-1 medication, or appetite suppressant?

YesNo

Have you ever stopped a medication because of side effects?

YesNo

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Injection Readiness

Your comfort level with self-injection.

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Medical History

Please answer all medical history questions honestly. This information is critical for your safety.

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Labs & Bloodwork

Recent lab work helps us assess your baseline.

Do you have recent bloodwork?

YesNo

When was it done?

Upload lab reports

📎Click to upload filesPDF, JPG, PNG, DOC (max 10MB each)

Has a provider reviewed your bloodwork?

YesNo

Any abnormal lab values you are aware of?

Have you had recent glucose / A1C / lipid / thyroid labs?

YesNo

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Lifestyle Screening

Understanding your current lifestyle helps us personalize your protocol.

Typical meals per day

Are you aware of your protein intake?

YesNo

Daily water intake

Alcohol use

Exercise frequency

Sleep quality

Stress level

Are you prepared to follow a structured protocol for at least 12 weeks?*

YesNo

Do you understand that stopping too early may reduce results?*

YesNo

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Screening Questions

A few final questions to help us serve you better.

What concerns you most about starting?

What are you hoping this program improves first?

Are you looking for a short-term fix or long-term change?

Short-term fixLong-term changeBoth

Have you worked with a clinic like this before?

YesNo

Is cost a concern for ongoing adherence?

YesNo

Are you ready for consistent follow-up?

YesNo

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Acknowledgements & Consent

Please read each statement carefully and confirm your understanding.

Your Initials*

Full Legal Name*

Signature*

By typing your name above, you are providing your electronic signature.

Date Signed*

GLP-3 Wellness Clinic Intake & Consent

Basic Information

Goals & Reason for Inquiry

Prior Experience

Injection Readiness

Medical History

Labs & Bloodwork

Lifestyle Screening

Screening Questions

Acknowledgements & Consent

Thank You

Ticket Submitted

GLP-3 Wellness Clinic Intake & Consent

Basic Information

Goals & Reason for Inquiry

Prior Experience

Injection Readiness

Medical History

Labs & Bloodwork

Lifestyle Screening

Screening Questions

Acknowledgements & Consent

Thank You

Client Portal

Age Verification Required

Ticket Submitted