Purpose: Rapid eligibility screening, safety triage, and insurance-ready documentation. Thisform is designed to be completed in 5–7 minutes.
IDENTITY & TELEHEALTH ELIGIBILITY
ANTHROPOMETRICS & MEDICAL NECESSITY
ABSOLUTE CONTRAINDICATION SCREEN
PRIOR GLP-1 & SAFETY FLAGS
INSURANCE & ACCESS
INFORMED CONSENT
Massachusetts Telehealth & Treatment Consent
By proceeding, I acknowledge and agree that:
• I am physically located in the Commonwealth of Massachusetts at the time of this encounter. • I consent to receiving medical evaluation and treatment via telehealth in accordance with Massachusetts law. • I understand that telehealth has limitations, including the inability to perform a physical examination. • I understand that GLP-1 medications are FDA-approved for diabetes and/or obesity and may be prescribed off-label when clinically appropriate. • I understand the potential risks, benefits, alternatives, and side effects of GLP-1 therapy, including gastrointestinal symptoms and rare but serious risks. • I understand that ongoing monitoring, follow-up visits, and laboratory testing may be required. • I understand that my provider may determine that GLP-1 therapy is not appropriate for me based on clinical judgment.