GLP-1 Clinic Intake Paperwork: What Your Forms Need to Cover Before the First Injection

GLP-1 receptor agonist clinics are everywhere. Whether you're a weight loss clinic, a med spa adding Ozempic or Mounjaro to your service line, or a primary care practice that's seen demand explode, the clinical and legal landscape around these medications demands intake paperwork that goes well beyond a standard new patient form.

These are powerful medications with serious contraindications, a long list of potential side effects, and a patient population that often arrives with complex medical histories—diabetes, cardiovascular disease, thyroid conditions, psychiatric medications, and more. Your intake forms need to capture all of it before a single dose is prescribed or administered.

Why GLP-1 Intake Paperwork Is Different

Quick answer: GLP-1 receptor agonists carry specific contraindications, FDA boxed warnings, and a well-documented side effect profile that generic health history forms aren't designed to screen for. The current litigation environment makes thorough documentation essential.

A standard medical intake form captures demographics, basic health history, allergies, and current medications. That's a starting point, but for GLP-1 prescribing it's not close to sufficient.

GLP-1 receptor agonists—semaglutide (Ozempic, Wegovy, Rybelsus), tirzepatide (Mounjaro, Zepbound), liraglutide (Saxenda, Victoza), and the growing list of compounded alternatives—carry specific contraindications that require explicit screening. The FDA labeling for these medications includes boxed warnings, and a generic health history form isn't designed to screen for them.

Beyond contraindications, GLP-1 patients need thorough informed consent. These medications have a well-documented side effect profile that patients need to understand before starting treatment. The informed consent conversation needs to be documented in writing, signed, and part of the patient's record. If a patient develops pancreatitis or gastroparesis six months into treatment and claims they were never told about the risk, your documentation is either your best defense or your biggest liability.

The practices getting this right are the ones with intake workflows designed specifically for GLP-1 prescribing. The ones getting it wrong are using their standard new patient forms and hoping for the best.

Medical History: What You Must Screen For

Quick answer: Your GLP-1 intake form needs direct, explicit questions with checkboxes for every condition that affects prescribing—not a generic "list your medical conditions" text box. Patients don't know what's medically relevant unless you ask them directly.

Thyroid history. GLP-1 receptor agonists carry an FDA boxed warning regarding thyroid C-cell tumors based on rodent studies. Your intake form needs to ask specifically: Have you ever been diagnosed with medullary thyroid carcinoma (MTC)? Do you have a family history of MTC? Have you been diagnosed with Multiple Endocrine Neoplasia syndrome type 2 (MEN2)? Do you have a history of thyroid nodules, thyroid cancer of any type, or thyroid surgery? These can't be buried in a general medical history checklist—they need to be prominent, explicit questions that the patient can't easily skip past.

Pancreatitis. GLP-1 medications are associated with an increased risk of pancreatitis. The form should ask: Have you ever been diagnosed with pancreatitis? Do you have a history of gallstones or gallbladder disease? Do you have elevated triglycerides? Heavy alcohol use? These are direct risk factors that influence whether and how you prescribe.

Gastroparesis and GI history. GLP-1 medications slow gastric emptying—that's part of how they work. For patients with pre-existing gastroparesis, inflammatory bowel disease, or a history of bowel obstruction, this is a significant clinical consideration. Your form should ask about these conditions directly, not rely on the patient to volunteer them.

Diabetes status and current management. Many GLP-1 patients are already on diabetes medications. If a patient is on insulin or a sulfonylurea and you add a GLP-1, the hypoglycemia risk is real. Your form needs to capture not just "do you have diabetes" but what medications they're currently taking, their most recent A1c if known, and whether they're experiencing any episodes of low blood sugar.

Psychiatric history and eating disorders. GLP-1 medications have been associated with reports of suicidal ideation, and the FDA has investigated this signal. Additionally, prescribing weight loss medications to patients with a history of anorexia nervosa or bulimia carries distinct clinical and ethical considerations. Your intake form should screen for current or past eating disorders, current psychiatric medications, and history of depression, anxiety, or suicidal ideation. These are sensitive questions, but they're clinically necessary.

Kidney and liver function. Renal impairment affects dosing and monitoring for some GLP-1 medications. Your form should ask about known kidney disease, dialysis, liver disease, or abnormal lab values.

Pregnancy and reproductive status. GLP-1 medications are contraindicated in pregnancy and should be discontinued well before a planned pregnancy. Your form needs to ask about current pregnancy, breastfeeding, and plans to become pregnant. For tirzepatide specifically, there are considerations around oral contraceptive efficacy due to delayed gastric emptying.

Surgical history. Patients with a history of bariatric surgery, bowel resection, or other GI surgeries may have altered absorption and GI function that affects how they respond to GLP-1 medications. Ask specifically.

Current medications—all of them. GLP-1 medications interact with oral medications because of delayed gastric emptying. This is especially relevant for medications with narrow therapeutic windows—oral contraceptives, warfarin, levothyroxine, certain antiepileptics. Your form should capture a complete medication list and specifically ask about these categories.

Every one of these questions should be a direct, explicit field in your intake form—not a line in a paragraph the patient skims past, and not a text box where they write "none" because nothing comes to mind.

Informed Consent: Don't Shortcut This

Quick answer: GLP-1 informed consent must be its own document, covering the specific medication, expected side effects, serious risks, weight regain after discontinuation, off-label status if applicable, and monitoring requirements. A chart note saying "risks and benefits discussed" is not sufficient.

Informed consent for GLP-1 medications needs to be its own document, separate from your general treatment consent. It should be written in plain language, and it needs to cover the following at minimum:

The specific medication being prescribed, including whether it's an FDA-approved product or a compounded version. This distinction matters—compounded semaglutide and tirzepatide carry different risk profiles and regulatory status than brand-name products, and your patient needs to understand what they're getting.

Expected side effects. Nausea, vomiting, diarrhea, and constipation are common, especially during dose titration. Patients need to know this upfront so they don't panic at week two and so they can't later claim they weren't warned.

Serious risks. Pancreatitis, gallbladder disease, gastroparesis, bowel obstruction, thyroid tumor risk (with appropriate context about the rodent study data), potential for hypoglycemia when combined with other diabetes medications, injection site reactions, and the emerging data around suicidal ideation. You don't need to frighten patients, but you do need to inform them.

What happens when they stop. Patients should understand that weight regain after discontinuation is well-documented in the clinical literature. This isn't a scare tactic—it's informed consent. Setting expectations upfront also reduces complaints and dissatisfaction later.

The off-label nature of the prescription, if applicable. Ozempic is FDA-approved for type 2 diabetes, not weight loss. Mounjaro was originally approved for diabetes before Zepbound received the weight loss indication. If you're prescribing off-label, the patient should know and consent to that specifically.

Monitoring requirements. What lab work is expected and how often. What symptoms should prompt them to contact you immediately (severe abdominal pain, vision changes, signs of thyroid enlargement). What the follow-up schedule looks like.

This consent form should be signed, dated, timestamped, and stored as part of the patient record. It should not be a verbal conversation that you document with a chart note saying "risks and benefits discussed." That's not sufficient for this class of medication given the current litigation environment.

Compounded GLP-1s: Additional Paperwork Considerations

Quick answer: Compounded semaglutide and tirzepatide require additional consent documenting that the medication is not FDA-approved, may differ from brand-name formulations, and tracking the compounding pharmacy, lot numbers, and beyond-use dates.

If your clinic prescribes compounded semaglutide or tirzepatide, your intake paperwork carries additional requirements.

The FDA has taken enforcement actions against compounding pharmacies, and the legal landscape is actively shifting. Your informed consent should specifically address the fact that compounded medications are not FDA-approved, that they may differ from brand-name products in formulation, and that the patient understands and accepts this distinction.

You should document which compounding pharmacy you're using and have a system for tracking lot numbers and beyond-use dates. While this is more of an operational than an intake concern, having a field in your intake workflow that captures which specific product a patient received (brand vs. compounded, pharmacy source, lot number) creates a defensible record if questions arise later.

Some practices also include a separate compounding-specific consent acknowledging the regulatory status of the medication. Given the current environment, this is a reasonable precaution.

A Note on Scope-of-Care Disclaimers

Quick answer: If you're a med spa or weight-loss clinic (not a primary care provider), a scope-of-care disclaimer defines the boundaries of your evaluation. Discuss this with your malpractice carrier—the five-minute phone call could save a significant headache.

Many GLP-1 clinics—especially med spas and weight loss-focused practices—are seeing patients for one specific purpose: weight management. You're not functioning as their primary care provider. You're not managing their hypertension, screening for cancer, or monitoring their mental health longitudinally. But without something in your paperwork that explicitly defines the boundaries of your evaluation, you could find yourself exposed if a patient later develops a condition that was outside the scope of what you were treating.

A scope-of-care disclaimer is a document that communicates to the patient that this evaluation and treatment are limited to a specific purpose—in this case, GLP-1-assisted weight management—and that the patient should maintain a relationship with a primary care provider for comprehensive health management. It's not a waiver of liability. It's a clear articulation of what you're doing and what you're not doing.

Whether and how to implement this depends on your state, your practice type, and your specific liability exposure. This is a conversation to have with your malpractice carrier or healthcare attorney. It's worth asking about.

Where Standard Intake Forms Fall Short

Quick answer: EMR intake forms don't include GLP-1-specific screening, don't support medication-specific consent documents, don't offer conditional logic for contraindication flagging, and can't handle compounding disclosures or lot tracking.

If you're running a GLP-1 program using your EMR's standard intake forms—or worse, a generic form builder—you're likely missing critical elements.

• No GLP-1-specific screening questions. They'll ask about allergies and current medications, but they won't ask directly about medullary thyroid carcinoma, MEN2 syndrome, history of pancreatitis, or eating disorders. Those questions need to be explicit and prominent.
• No medication-specific consent. You might have a general treatment consent, but a GLP-1-specific informed consent with all the elements listed above requires a purpose-built document.
• No conditional logic. If a patient reports a history of pancreatitis, your form should flag that and branch to additional screening questions. If a patient indicates they're currently pregnant, the form should stop and redirect. Generic form builders either don't support this or require extensive manual configuration.
• No compounding documentation. Consent forms, lot tracking fields, and pharmacy information captured in a structured way don't exist in standard EMR intake modules.

What a Complete GLP-1 Intake Workflow Looks Like

Quick answer: A six-step digital workflow: demographics, GLP-1-specific medical screening with conditional logic, weight and lifestyle history, medication-specific informed consent (plus compounding consent if applicable), financial documents, and general consents. All completed on the patient's device before the appointment.

The patient receives a link—via text, email, or a QR code in your office—and opens the intake forms on their own device. No clipboard, no pen, no illegible handwriting.

Step 1: Demographics and insurance. Standard patient information, plus specific fields for the referring provider if applicable, and how the patient heard about your GLP-1 program.

Step 2: GLP-1-specific medical history screening. The explicit, condition-by-condition screening described above. Thyroid history, pancreatitis, gastroparesis, diabetes management, psychiatric history, eating disorders, kidney and liver function, pregnancy status, surgical history, and a complete medication list with specific prompts for high-interaction medications. Conditional logic adapts the form based on responses—a "yes" to thyroid history triggers follow-up questions; a positive pregnancy screen stops the workflow.

Step 3: Weight and lifestyle history. Previous weight loss attempts, previous use of weight loss medications (including which ones and outcomes), current diet and exercise habits, weight loss goals, and any relevant lab work the patient can provide (recent A1c, metabolic panel, thyroid panel).

Step 4: GLP-1-specific informed consent. The dedicated consent document covering the specific medication, expected side effects, serious risks, what happens at discontinuation, off-label status if applicable, and monitoring requirements. If prescribing compounded medications, the compounding-specific consent is included here.

Step 5: Financial documents and policies. Many GLP-1 programs are cash-pay. Your financial agreement should be clear about pricing, what's included (medication, follow-up visits, lab work), refund policies, and what happens if the patient discontinues.

Step 6: General consents. HIPAA authorization, general treatment consent, telehealth consent if applicable, photo consent if you track progress photos.

The entire workflow is completed on the patient's device before they walk in the door (or before their telehealth appointment). Everything is signed, timestamped, and available as a unified record. Nothing is on a clipboard, nothing needs to be scanned, and nothing is missing when the provider sits down with the patient.

Frequently Asked Questions

What medical conditions must GLP-1 intake forms screen for?

GLP-1 intake forms must explicitly screen for: medullary thyroid carcinoma (MTC) and MEN2 syndrome (FDA boxed warning), history of pancreatitis and gallbladder disease, gastroparesis and GI conditions, current diabetes medications (hypoglycemia risk with insulin/sulfonylureas), psychiatric history including eating disorders and suicidal ideation, kidney and liver disease, pregnancy and reproductive status, surgical history (especially bariatric/GI), and a complete medication list with focus on narrow-therapeutic-window drugs affected by delayed gastric emptying.

Do I need a separate informed consent for GLP-1 medications?

Yes. GLP-1 informed consent should be its own document, separate from general treatment consent. It must cover: the specific medication (brand vs. compounded), expected side effects (nausea, vomiting, diarrhea, constipation), serious risks (pancreatitis, gallbladder disease, gastroparesis, thyroid tumor warning, suicidal ideation data), weight regain after discontinuation, off-label status if applicable (Ozempic for weight loss is off-label), and monitoring requirements. A chart note saying "risks and benefits discussed" is not sufficient for this medication class.

What additional paperwork is needed for compounded semaglutide or tirzepatide?

Compounded GLP-1 medications require additional consent documentation addressing: the fact that compounded medications are not FDA-approved, potential differences from brand-name formulations, the patient's understanding and acceptance of this distinction, and tracking fields for compounding pharmacy, lot numbers, and beyond-use dates. Given FDA enforcement actions against compounding pharmacies, a separate compounding-specific consent is a reasonable precaution.

Why don't standard EMR intake forms work for GLP-1 clinics?

Standard EMR intake forms capture demographics, basic health history, and allergies—but they don't include GLP-1-specific screening questions for medullary thyroid carcinoma, MEN2, pancreatitis history, or eating disorders. They don't support medication-specific informed consent documents, conditional logic (flagging contraindications or stopping the workflow for pregnancy), compounding disclosures, or lot tracking.

Should GLP-1 clinics include a scope-of-care disclaimer?

It's worth discussing with your malpractice carrier. A scope-of-care disclaimer communicates that your evaluation and treatment are limited to GLP-1-assisted weight management, and that the patient should maintain a primary care relationship for comprehensive health management. This is especially relevant for med spas and weight loss-focused practices that aren't functioning as primary care providers.

How much does EasyDocForms cost for GLP-1 clinics?

EasyDocForms is $49/month flat—unlimited providers, unlimited patients, unlimited forms. Includes white-glove onboarding where the team builds your custom GLP-1 intake forms for you based on your clinical requirements, state, and practice model. Also includes conditional logic, medication-specific consent documents, digital signatures with timestamps, AI-powered form digitization, and HIPAA compliance with signed BAA.