HAVO Pharmacy - Patient Medical Form

Personal Information

Name*

Email*

Phone*

Date of Birth*

Address*

Address Line 2

City

State

Zipcode

Weight (lbs)

Height

Sex*

Male

Female

Race

Product Selection

Desired Product*

Quantity for Tirzepatide (10mg) + B6*

Quantity for Tirzepatide (20mg) + B6*

Quantity for Tirzepatide (30mg) + B6*

Quantity for Tirzepatide (40mg) + B6*

Quantity for Tirzepatide (50mg) + B6*

Quantity for Tirzepatide (60mg) + B6*

Quantity for 1000mg/3ml of NAD+*

Quantity for 6mg/3ml of Sermorelin*

Quantity for 7mg/1mg/3ml of Bremelanotide and Oxytocin*

Medical History & Health Information

Patient Type*

New patient/Refill

Existing Patient

WHAT ARE YOUR GOALS?* (Select at least one)

Energy

Performance / Lean

Hormone Balance / Fertility / PCOS

Weight Loss

Help my Deficiency

Immune Boost

Skin

General Wellness

Mood / Focus / Stress

Inflammation

Detox

Other

Allergies

Occupation

Past Medical History

Do you have any of the following conditions? (Select all that apply)

Fibromyalgia

Chronic Fatigue Syndrome

Liver or Kidney problems

Heart Problems

High Blood Pressure

Thyroid Issues

Hormone Issues

Blood Clots

Pre/Peri/Post Menopause

Cancer

Stroke or Seizure

Thyroid Cancer

None

Health Screening Questions

Do you have a history of diabetes?

Yes

Do you have a history of thyroid cancer?

Yes

Do you have any kidney issues?

Yes

Have you ever had pancreatitis?

Yes

Do you have Type 1 diabetes?

Yes

Are you currently taking blood thinners?

Yes

Current Medications

Alcohol Consumption

Yes

If yes, how often?

Have you used GLP-1 medications before? (e.g., Ozempic, Wegovy, Mounjaro)

Yes

Additional Health Conditions (Select all that apply)

Cancer (current or history)

Liver Disease

Autoimmune Disorder

Sleep Apnea

Stroke

Obesity Contributing Factors (Select all that apply)

Poor Diet

Sedentary Lifestyle

Genetic Factors

Medical Conditions

Medications

Hormonal Imbalance

Current Healthcare Professional

Questions for Doctor

Consent & Signature

Please read and acknowledge the following statements by checking each box:

I understand that this medication is prescribed for weight management and metabolic health improvement.

I have disclosed all relevant medical history, current medications, and health conditions to the best of my knowledge.

I understand that this medication may cause side effects including nausea, vomiting, diarrhea, constipation, and decreased appetite.

I will immediately report any severe side effects or adverse reactions to my healthcare provider.

I understand that this medication should not be used if I am pregnant, planning to become pregnant, or breastfeeding.

I will follow the prescribed dosing schedule and will not adjust my dose without consulting my healthcare provider.

I understand that results may vary and that this medication is most effective when combined with a healthy diet and regular exercise.

I authorize HAVO Pharmacy to contact me regarding my treatment, prescription refills, and follow-up care.

I understand that I am responsible for the cost of this medication and any associated fees.

I certify that all information provided in this form is true and accurate to the best of my knowledge.

Patient Signature* By typing your name, you are providing your electronic signature.

Date*

Patient Medical Form

Complete Your Health Assessment

Personal Information

Product Selection

Medical History & Health Information

Health Screening Questions

Consent & Signature