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Medical intake

A licensed provider reviews everything you share here
Patient
Preview / test mode. This form is for testing the flow only. Do not enter real patient information yet — real medical data can be collected only after Veritide Health's privacy/security safeguards (including a signed BAA) are in place. Consent text below is draft placeholder and must be replaced with your attorney-reviewed language before launch.

What are you seeking care for? *

This routes your intake to a clinic that treats this condition in your state.

What brings you in?

Tell us about your symptoms, concerns, or goals so the provider understands what you're looking for.

About you

Basic profile details.
Your state determines which licensed clinics can treat you, and treatment ships to this address.

Health basics

Medical history

List anything relevant — write "none" if not applicable.

Lifestyle & GLP-1 history

A few questions about your care

These help the provider understand your situation. Your answers go only to the clinic that reviews your request.

Safety screening

Any "yes" routes your intake to provider review. Nothing is auto-approved.

When are you available for a consult?

Your clinic books the earliest time that fits — the more you select, the faster you'll be seen. You can fine-tune this anytime from your dashboard.

Consent & signature

Please read each consent and indicate your agreement.
1. Telehealth consent & Notice of Privacy Practices
This is a telehealth service. Care is provided remotely and may have limitations compared to in-person care. You consent to evaluation and, where appropriate, treatment via telehealth. Your health information is handled according to our Notice of Privacy Practices. You may withdraw consent at any time. Telehealth is not for emergencies — for emergencies call 911.
[Draft placeholder — replace with your attorney-reviewed, state-specific telehealth consent and Notice of Privacy Practices before serving real patients.]
2. Treatment / informed consent
You consent to medical evaluation and, if a provider determines it appropriate, prescription treatment. You understand the potential benefits, risks, and side effects of treatment, that individual results vary, and that you should follow provider instructions and report any adverse effects.
[Draft placeholder — replace with your attorney-reviewed informed consent.]
3. Compounded medication acknowledgment
You acknowledge that medications dispensed may be compounded preparations prepared by a licensed pharmacy for patient-specific use, that compounded medications are not FDA-approved products, and that correct dosing and storage are important. You agree to report any adverse events or medication errors.
[Draft placeholder — replace with your attorney-reviewed acknowledgment.]

Type your full legal name to sign all three consents electronically. This is your electronic signature.

Most Veritide treatments are self-pay. If your treatment is billable to insurance, we'll match you with a clinic that accepts your carrier — you'll confirm coverage with the clinic.