Retatrutide Patient Intake Form Template
Retatrutide is a next-generation triple agonist targeting the GIP, GLP-1, and glucagon receptors, showing up to 24% average body weight reduction in Phase 2 trials. This intake form covers contraindication screening, weight-related comorbidities, symptom assessment, and prior GLP-1 medication history. Designed for providers prescribing compounded Retatrutide or managing patients in clinical research access programs, the form aligns with GLP-1 class prescribing standards and investigational use documentation requirements.
Free Template
Retatrutide Patient Intake Form
Form Preview
This is how the form appears to patients. Customize with your practice name and branding.
Your Practice Name
Retatrutide Patient Intake Form
1 General Patient Information
Please provide your personal information.
General Patient Information
Please provide your personal information.
First Name
Jane
Last Name
Smith
Date of Birth
—
Can you confirm you are 18 years or older?
Height
e.g. 5'8"
Weight
e.g. 170 lbs
2 Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Medical History
Please answer all questions as accurately as possible. Your provider will review this information.
Are you actively taking any medications? If so, please list them.
List all current medications, dosages, and frequencies
Do you have any medication allergies? If so, please list them.
List all known drug allergies and reactions
Are you currently being treated or have you been treated for any medical conditions? If so, please list them.
List all current and past medical conditions
Have you had any past surgeries? If so, please list them.
List all surgeries and approximate dates
What is/was your sex assigned at birth?
Male
Emergency contact name and phone number
Name — (555) 000-0000
Mailing address
123 Main St, City, State, ZIP
Any other questions or concerns?
Optional — share anything else you'd like your provider to know
3 Contraindications
Please select any conditions that apply to you.
Contraindications
Please select any conditions that apply to you.
4 Weight-Related Conditions
Select any conditions you have been diagnosed with.
Weight-Related Conditions
Select any conditions you have been diagnosed with.
5 Symptoms
Select all symptoms you are currently experiencing.
Symptoms
Select all symptoms you are currently experiencing.
6 Prior GLP-1 Use
Please answer the following about any prior GLP-1 or weight loss injection use.
Prior GLP-1 Use
Please answer the following about any prior GLP-1 or weight loss injection use.
Are you actively taking or have you recently taken any GLP-1 medications?
If yes, when was your last injection date?
—
If yes, how many months have you been taking GLP-1 medications?
e.g. 3
If yes, please upload an image of your current medication or prescription.
Click to upload or drag and drop
Preview only. Your live form will include your branding and e-signature capture.
Compliance & Regulatory Notes
Review these notes before deploying this form in your practice.
Retatrutide is an investigational triple agonist (GIP, GLP-1, and glucagon receptors) and is not yet FDA-approved as of 2025. Compounded or research-use formulations require explicit informed consent and must be prescribed under appropriate regulatory frameworks. See FDA: https://www.fda.gov/patients/fast-track-breakthrough-therapy-accelerated-approval-priority-review/breakthrough-therapy
Prescribers must screen for personal or family history of Medullary Thyroid Carcinoma (MTC) or Multiple Endocrine Neoplasia Syndrome Type 2 (MEN 2) before initiating therapy, consistent with GLP-1 class labeling requirements.
Retatrutide has demonstrated significant weight reduction in Phase 2 trials. Providers should document BMI, comorbidities, and prior weight loss attempts at baseline. See: https://www.nejm.org/doi/full/10.1056/NEJMoa2301972
Patients with a history of pancreatitis, gallbladder disease, or diabetic retinopathy should be evaluated carefully before initiating therapy.
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Sources & References
Frequently Asked Questions
What makes Retatrutide different from other GLP-1 medications?
Retatrutide activates three receptors simultaneously: GIP (glucose-dependent insulinotropic polypeptide), GLP-1 (glucagon-like peptide-1), and glucagon. This triple-agonist mechanism produced greater average weight loss in Phase 2 trials (up to 24% body weight reduction) compared to dual or single agonists like semaglutide or tirzepatide.
Is Retatrutide FDA-approved?
As of 2025, Retatrutide is not yet FDA-approved. It is in late-stage clinical trials. Any access to Retatrutide outside of a clinical trial is through compounding pharmacies under a prescriber's order. Patients should understand this distinction and provide informed consent.
What side effects should I expect?
The most common side effects are gastrointestinal: nausea, vomiting, diarrhea, and constipation, consistent with the GLP-1 class. These typically diminish after the first few weeks of therapy. Rare but serious risks include thyroid tumors, pancreatitis, and hypoglycemia in patients on concomitant insulin or sulfonylureas.