Intake Form | The Edit Haus

Please complete this intake form before submitting for clinical review. Required for order review.

First name

Last name

Date of birth

Month

Day

Year

Teléfono

Email address

Rate your agreement with this statement: “My weight is negatively impacting my quality of life."

Height (Include your height first feet and then inches):

What is your current weight?

Have you ever taken or are you currently taking a GLP-1 medication?

Yes

No

Are you currently pregnant, breastfeeding, or planning to becom pregnant within the next two months?

Yes

No

Are you currently taking any medications including prescription, over-the-counter, and supplements?

If you answered yes, please list all medications you are currently taking:

Please list all of your known allergies. Please type N/A if none.

Please upload a government-issued form of ID (Driver’s License, Passport, etc.):

What type of consultation would you prefer?

Email and Text Message (Fastest Option)

Video

Phone Call

How did you find The Edit Haus?

By submitting this form I authorize The Edit Haus to evaluate the submitted information and to contact me. I understand that the treatment is subject to medical evaluation and approval and that telehealth consultation is required prior to any treatment.

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