Contains similar active ingredients found in leading brands.

Patient Questionnaire

Patient Information

First Name
Last Name
Date of Birth
Mobile Phone Number
Email
Height
Weight(Pounds)
Gender
Address
City
State
Zip

Weight Loss

Do you suffer from type 1 or type 2 diabetes?
What Medications do you take for your diabetes?

Do you have High Blood Pressure/Heart Problems?
Please list all heart issues and medications you take for them.
Are you pregnant or breastfeeding?
Do you have any major medical conditions?
Major Medical Conditions:
Do you take any medications?
Medications:
Do you have medication allergies (Seasonal, Medication or any other)?
Medication Allergies:
Have you seen the doctor in the last 12 months?
What is the reason you want to lose weight?
What is your weekly alcohol intake?
Do you or have you ever smoked?
Have you ever had an allergic reaction to Mounjaro, Tirzepatide, Semaglutide or any other GLP1?
Have you ever been diagnosed with Multiple Endocrine Neoplasia syndrome?
Do you have a personal or family history of thyroid cancer?
Please specify:
Have you ever been diagnosed with gallbladder, Pancreas, heart or kidney problems?
Please explain:
Have you ever had thoughts of self harm or suicide?
Have you tried other diet methods, Exercise or any other medications?
Please list:

FDA Disclaimer: LipozeneRx relies upon the general body of scientific evidence and studies related to Semaglutide. These statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease. It is imperative to read the entire label and follow the recommended usage instructions.

Safety Warning: GLP-1 medications may have serious side effects. Do not use if you or your family have a history of a type of thyroid cancer called MTC or MEN 2. In rodents, they cause thyroid C-cell tumors and their impact in humans is unknown.

We offer a 30-day money-back guarantee for all our products on initial shipment only. For more information, please refer to our refund policy.

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