Thanks for your interest in our program.

There may be many different benefits to the GLP-1 class of medication beyond weight loss and diabetes management. Are you aware that “micro-dosing” GLP-1 means using lower-than-standard doses? The program consists of using these medications at low doses to obtain the potential added benefits of this medication.

Would you like to continue?

What is your height in feet and inches?

What is your weight in pounds?

Your BMI is 0.00

This is one part of the provider’s review.

A few quick details for provider review

These details help confirm safety considerations.

Calendar, identification card, gender symbols, and birthday cake Control RX microdosing program

Which outcomes are you most interested in?

Select all that apply.

Microdosing goals
How long has this been a concern for you?

Have you ever used a GLP-1 medication?

For example: semaglutide, liraglutide, or tirzepatide.

Previous GLP-1 use

Which medication did you take?

Select all that apply.

Previous medication

Did you experience any side effects?

Previous side effects

Please check all current or past medical conditions

Select all that apply.

Medical conditions
Please confirm your choice

Please state all your current medical conditions

Have you had gastric bypass in the past 6 months?

Recent gastric bypass

Are you allergic to any of the following?

GLP-1 allergies

Do you take any of the following medications?

Insulin
Glimepiride (Amaryl)
Meglitinides such as repaglinide or nateglinide
Glipizide (Glucotrol and Glucotrol XL)
Glyburide (Micronase, Glynase, and Diabeta)
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
Medication risk

What other information or questions do you have for the doctor?

Consent (Truthfulness)

Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided are true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.

Truthfulness consent

Consent (Medication Specific)

You are requesting micro-dose therapy with a GLP-1 receptor agonist (e.g., semaglutide) or a GIP/GLP-1 receptor agonist (e.g., tirzepatide) to support metabolic health, appetite regulation, reduction of inflammation, and cellular well-being. These very low doses are below the standard therapeutic range and are intended to explore potential wellness benefits. This is considered “off-label” and is not an FDA approved use of this medication.

Compounded Formulations

Compounded semaglutide and tirzepatide are custom-prepared by a licensed pharmacist to meet individual needs. Because compounded medications are not subject to the same extensive clinical trials as FDA-approved products, their consistency, efficacy, and safety profiles may vary.

Potential Benefits

  • Support for metabolic balance and appetite control
  • Potential reduction in systemic inflammation
  • Early/preliminary neuroprotective or anti-aging effects
  • Enhancement of cellular “well-being”

Potential Side Effects

Although micro-dosing may lower risk, these therapies can still cause adverse reactions, including nausea, vomiting, diarrhea or constipation, decreased appetite, indigestion, pancreatitis, gallbladder issues, kidney impairment, allergic reactions, and gastroparesis.

Risks and Considerations

Compounded formulations may vary in potency and purity. Inform your provider immediately if you experience side effects.

Monitoring and Follow-Up

Regular follow-up visits will assess your response, adjust dosing, and monitor for side effects.

Acknowledgment and Consent

I have read and understand the information above regarding micro-dose GLP-1/GIP–GLP-1 therapy, including its compounded nature, potential benefits, risks, and monitoring requirements.

Medication consent