Draft v0.1 · Document B3
Patient Intake Attestations
Statements the patient confirms at intake, by program.
Patient Intake Attestations
Version [VERSION] | Effective [EFFECTIVE DATE] | Last updated [LAST UPDATED]
How to read this form. Each part is a table. “What the patient sees” is the exact wording. “Reviewed by” means: System, an automatic rule in GEN Health; WellPeps (non-clinical), WellPeps support staff who check only account, shipping and eligibility details and never judge health answers; Clinician, a licensed clinician of [PRACTICE NAME] (the Practice).
Before you start (shown at the top of the form)
Please answer every question honestly and completely. Your answers help clinicians of the Practice decide whether and how they can treat you. A clinician of the Practice, not WellPeps, reviews your health answers and makes every medical decision. Answering these questions does not make you a patient of the Practice. That happens only when a clinician accepts you.
Part A. About you: identity and eligibility
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
A.1 | Full legal name (as shown on your photo ID) | Patient Data Field (name) | Required | System; Clinician |
A.2 | Date of birth | Date. Disqualifier: Patient is younger than 18 (see build notes for 19 and 21) | Required | System |
A.3 | What sex were you assigned at birth? | Radio: Female, Male, I would rather explain in a message | Required | Clinician |
A.4 | Gender identity (only if you want your clinician to know) | Short Text | Optional | Clinician |
A.5 | Email address, mobile phone number and home address | Patient Data Field (email, phone, address) | Required | System; WellPeps (non-clinical) |
A.6 | I am at least 18 years old. If I live in Alabama or Nebraska, I am at least 19. If I live in Mississippi, I am at least 21. [VERIFY: age of majority by state] | Checkbox (single option: I agree) | Required | System |
A.7 | In which state do you live (your home state)? | Dropdown: states served | Required | System; Clinician |
A.8 | I live in the United States, in a state where WellPeps services are offered (see States We Serve). | Checkbox (single option: I agree) | Required | System |
A.9 | If asked, I will give a clear photo of a valid government-issued photo ID and a photo of myself, so the Practice or WellPeps can confirm who I am. [VERIFY: ID verification requirement] | Checkbox (single option: I agree); File Upload (PNG, JPG, HEIC or PDF) | Statement required; upload when requested | Clinician (WellPeps may pre-check) |
A.10 | This account is for me. I will not share my login, create more than one account, or order medicine for anyone else. | Checkbox (single option: I agree) | Required | System |
A.11 | I am asking for this care myself. No one is pressuring me. | Checkbox (single option: I agree) | Required | System |
Part B. Where you are right now (a short form asked every time)
Shown with every new order, every refill and every request for a visit.
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
B.1 | In which state are you physically located right now? | Dropdown: states served, plus Another state or outside the United States. Disqualifier: any answer outside [STATES SERVED] | Required | System; Clinician |
B.2 | If this is different from the state you live in, how long will you be there? | Short Text | Required if different | Clinician |
B.3 | I understand that clinicians must be licensed where I am physically located during my care. I will update my location before every visit, refill or request for care, and I will not ask for care while I am outside [STATES SERVED]. [VERIFY: care while outside the state] | Checkbox (single option: I agree) | Required | System |
B.4 | I understand that state rules may limit where medicine can be shipped. I will give a delivery address where I can receive it safely. | Checkbox (single option: I agree) | Required | WellPeps (non-clinical) |
Part C. Your health: questions for everyone [MEDICAL DIRECTOR TO CONFIRM]
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
C.1 | Height and weight | BMI | Required | Clinician |
C.2 | Which of these do you have, or have you ever had? Choose all that apply: heart disease or heart rhythm problem; high blood pressure; low blood pressure; stroke; diabetes or prediabetes; kidney disease; liver disease; thyroid disease; any cancer; pancreas, gallbladder, stomach or bowel disease; blood clotting or blood disorder; seizures; mental health condition; eating disorder; none of these. | Checkbox (list) | Required | Clinician |
C.3 | Tell us more about anything you chose, and about any other medical condition. | Long Text | Required if any chosen | Clinician |
C.4 | List every medicine you take: prescription medicine, over-the-counter medicine, vitamins, supplements, hormones and peptides, including anything you got from another source. Include the dose. Write “none” if you take nothing. | Long Text | Required | Clinician |
C.5 | Do you have any allergies to medicines, foods, dyes or other products? | Radio: Yes, No, Not sure | Required | Clinician |
C.6 | If yes, list each allergy and what happened. | Long Text | Required if yes | Clinician |
C.7 | Have you ever had a bad reaction to a medicine like the one you are asking about? | Radio: Yes, No, Not sure; Long Text if yes | Required | Clinician |
C.8 | Are you pregnant, trying to become pregnant, or breastfeeding? | Radio: Yes, No, Not applicable to me | Required | Clinician |
C.9 | Have you been in the hospital or had surgery in the last 12 months? | Radio: Yes, No, Not sure; Long Text if yes | Required | Clinician |
C.10 | Do you smoke or vape, drink alcohol, or use recreational drugs? Tell us how much. | Long Text | Optional | Clinician |
Part D. Your health: questions for the program you chose [MEDICAL DIRECTOR TO CONFIRM]
Part D shows only the section for the program you chose. Every row in Part D is required and is reviewed by a clinician. Rows marked Radio use Yes, No, Not sure.
D1. Weight Loss
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
D1.1 | Have you or a close family member ever had medullary thyroid cancer? | Radio: Yes, No, Not sure | Required | Clinician |
D1.2 | Have you been told you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)? | Radio: Yes, No, Not sure | Required | Clinician |
D1.3 | Have you ever had pancreatitis (inflammation of the pancreas)? | Radio: Yes, No, Not sure | Required | Clinician |
D1.4 | Have you had gallbladder disease or had your gallbladder removed? | Radio: Yes, No, Not sure | Required | Clinician |
D1.5 | Do you have gastroparesis (slow stomach emptying) or another serious stomach or bowel problem? | Radio: Yes, No, Not sure | Required | Clinician |
D1.6 | Do you have diabetes? If yes, do you use insulin or a sulfonylurea medicine? | Radio: Yes, No, Not sure; follow-up Radio if yes | Required | Clinician |
D1.7 | Do you have diabetic eye disease or other vision problems? | Radio: Yes, No, Not sure | Required | Clinician |
D1.8 | Have you ever had a serious allergic reaction to semaglutide, tirzepatide or another GLP-1 medicine? | Radio: Yes, No, Not sure | Required | Clinician |
D1.9 | Do you use, or have you recently used, any other GLP-1 or weight-loss medicine? | Radio: Yes, No, Not sure; Long Text for names and dates | Required | Clinician |
D1.10 | Do you take birth control pills? | Radio: Yes, No, Not sure | Required | Clinician |
D1.11 | Do you have surgery or a procedure with anesthesia or deep sedation planned? | Radio: Yes, No, Not sure; Short Text for the date | Required | Clinician |
D2. Sexual Wellness (currently offered to men only) [VERIFY: men-only eligibility wording]
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
D2.1 | Do you take any nitrate medicine (for example for chest pain), riociguat, or use “poppers” (nitrites)? | Radio: Yes, No, Not sure | Required | Clinician |
D2.2 | In the last 6 months, have you had a heart attack, a stroke or a serious irregular heartbeat? | Radio: Yes, No, Not sure | Required | Clinician |
D2.3 | Do you get chest pain, shortness of breath or dizziness with sex, or when you climb two flights of stairs? | Radio: Yes, No, Not sure | Required | Clinician |
D2.4 | Has a doctor ever told you that sexual activity is not advisable for your heart? | Radio: Yes, No, Not sure | Required | Clinician |
D2.5 | Do you have low blood pressure, or high blood pressure that is not controlled? | Radio: Yes, No, Not sure | Required | Clinician |
D2.6 | Do you take an alpha-blocker or another blood pressure medicine? | Radio: Yes, No, Not sure | Required | Clinician |
D2.7 | Do you take any other medicine for erectile dysfunction or for pulmonary hypertension? | Radio: Yes, No, Not sure | Required | Clinician |
D2.8 | Have you ever had sudden vision loss or sudden hearing loss, or been told you have retinitis pigmentosa? | Radio: Yes, No, Not sure | Required | Clinician |
D2.9 | Have you ever had an erection that lasted more than 4 hours, or do you have sickle cell disease, leukemia, multiple myeloma, or a curve or deformity of the penis (such as Peyronie’s disease)? | Radio: Yes, No, Not sure | Required | Clinician |
D2.10 | Do you have a bleeding disorder or an active stomach ulcer? | Radio: Yes, No, Not sure | Required | Clinician |
D2.11 | Do you have blood in your urine, urinary problems that are getting worse, or a family history of prostate cancer? | Radio: Yes, No, Not sure | Required | Clinician |
D3. Hair
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
D3.1 | Have you had prostate problems or prostate cancer? | Radio: Yes, No, Not sure | Required | Clinician |
D3.2 | Have you had depression, anxiety, or thoughts of harming yourself? (If you are in crisis now, call or text 988.) | Radio: Yes, No, Not sure | Required | Clinician |
D3.3 | Do you have swelling in your legs, ankles or face, or have you been told you have fluid around your heart? | Radio: Yes, No, Not sure | Required | Clinician |
D3.4 | Do you take medicine for blood pressure or your heart, or any nitrate? | Radio: Yes, No, Not sure | Required | Clinician |
D3.5 | Do you have a scalp condition, an open sore, or irritation on your scalp? | Radio: Yes, No, Not sure | Required | Clinician |
D3.6 | Have you ever had a reaction to finasteride, dutasteride, minoxidil or tretinoin? | Radio: Yes, No, Not sure | Required | Clinician |
D3.7 | Do you live with, or will you handle medicine around, someone who is pregnant or may become pregnant? | Radio: Yes, No, Not sure | Required | Clinician |
D4. Healthy Aging and Vitality
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
D4.1 | Have you ever been diagnosed with cancer, or are you being checked for cancer or a tumor? | Radio: Yes, No, Not sure | Required | Clinician |
D4.2 | Do you have a pituitary, thyroid, adrenal or other hormone problem? | Radio: Yes, No, Not sure | Required | Clinician |
D4.3 | Do you have diabetes or prediabetes, or have you had low blood sugar? | Radio: Yes, No, Not sure | Required | Clinician |
D4.4 | Do you take a medicine that can raise serotonin, such as an SSRI, an SNRI, an MAOI or St. John’s wort? | Radio: Yes, No, Not sure | Required | Clinician |
D4.5 | Have you ever been told you have G6PD deficiency? | Radio: Yes, No, Not sure | Required | Clinician |
D4.6 | Have you ever had an allergic reaction to a vitamin, an amino acid or an injection? | Radio: Yes, No, Not sure | Required | Clinician |
D4.7 | Do you take a blood thinner? | Radio: Yes, No, Not sure | Required | Clinician |
D4.8 | Do you compete in a sport, or have a job, that tests for banned substances? | Radio: Yes, No, Not sure | Required | Clinician |
Part E. Your primary care provider
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
E.1 | Do you have a primary care provider (PCP)? | Radio: Yes, No | Required | Clinician |
E.2 | PCP name, clinic and phone or fax number | Short Text | Required if yes | Clinician |
E.3 | The Practice’s clinician may send information about my care to my PCP. I can change my mind at any time. (Optional.) [VERIFY: PCP notice] | Radio: Yes, No. See HIPAA Authorization Forms | Optional | Clinician |
E.4 | I understand that this service does not replace my primary care. I am responsible for following up with my own doctor for ongoing care and for any problem the clinician tells me to have checked. | Checkbox (single option: I agree) | Required | System |
Part F. Emergency contact
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
F.1 | Emergency contact name | Short Text | Required [PRACTICE TO CONFIRM] | Clinician |
F.2 | Relationship to you | Short Text | Required [PRACTICE TO CONFIRM] | Clinician |
F.3 | Emergency contact phone number | Phone | Required [PRACTICE TO CONFIRM] | Clinician |
F.4 | I agree that the Practice may contact this person, and emergency services, if a clinician believes I am in danger. | Checkbox (single option: I agree) | Required | System |
Part G. Truthfulness and your responsibilities
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
G.1 | My answers are true and complete to the best of my knowledge. I have not left out anything about my health, my medicines or my allergies. | Checkbox (single option: I agree) | Required | System |
G.2 | I will tell the clinician right away if anything changes, such as a new medicine, a new condition, pregnancy or a side effect. | Checkbox (single option: I agree) | Required | System |
G.3 | I understand that wrong or missing information can cause serious harm, and that a clinician may decline to treat me or end my care if I give false information. | Checkbox (single option: I agree) | Required | System |
G.4 | I understand that a clinician of the Practice decides whether I can be treated, that a prescription is not guaranteed, and that WellPeps is not a medical practice. | Checkbox (single option: I agree) | Required | System |
G.5 | I understand that this form is not for emergencies. I will call 911 in an emergency, and call or text 988 if I am in crisis. | Checkbox (single option: I agree) | Required | System |
G.6 | I understand that care by telehealth has limits, as the Informed Consent to Telehealth Services and Treatment explains, and that I will read and sign it. | Checkbox (single option: I agree) | Required | System |
Part H. Documents and messages
# | What the patient sees | Response type (GEN Health) | Required? | Reviewed by |
|---|---|---|---|---|
H.1 | I have agreed to the Electronic Records, Signatures and Communications Consent, which was shown before this form. | Checkbox (single option: I agree) | Required | System |
H.2 | Text messages about my care and account: I choose whether to get them, under the Text Messaging Terms. | Radio: Yes, No | Optional | System |
H.3 | I have received the Notice of Privacy Practices of the Practice, or I was given a link to it. [VERIFY: where the Notice of Privacy Practices acknowledgment is collected] | Checkbox (single option: I agree) | Required | System |
This form does not sign you up for marketing messages.
Part I. Review and sign
Please read your answers once more. Signing does not guarantee that a clinician will accept you or prescribe anything. A licensed clinician decides whether treatment is appropriate for you.
I have read this form (version [VERSION], effective [EFFECTIVE DATE]). My answers are my own, and they are true and complete.
Electronic signature
Field | Entry |
|---|---|
Typed full legal name | Typed by the patient |
State where I am physically located right now | Selected by the patient from the list of states served |
Date and time | Captured by the system |
Document version | Captured by the system |
IP address | Captured by the system |
By typing my name, I agree that my electronic signature is the legal equivalent of my handwritten signature, and that I have already agreed to receive and sign documents electronically (see the Electronic Records, Signatures and Communications Consent). This form does not by itself create a clinician-patient relationship. That relationship begins only when a clinician accepts me.