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Skinn-ee Bees, LLC

Patient Intake & Consent Form

Complete all required fields to help your Skinn-ee Bees provider prepare for your consultation. Your information is encrypted in transit and kept private in accordance with HIPAA.

1. Patient Information

Provide your legal name and preferred contact information.

Enter a 10-digit U.S. phone number.

2. Medical History

Share details about previous diagnoses, surgeries, and your family health background.

3. Social History

Select the option that best describes your lifestyle. Additional questions appear when needed.

Do you consume alcohol?
Do you take illicit drugs?
Do you take nicotine products?

4. Safety Questions

Each question is required. If you select “Yes”, please provide the requested additional details.

Do you take any other prescription or over-the-counter drugs, vitamins, or herbal supplements?
Do you have other medical conditions involving the pancreas, kidneys, gastroparesis, or digestion?
Do you take diabetes medications (insulin or sulfonylureas)?
Do you have a history of diabetic retinopathy?
Are you scheduled for surgery or anesthesia?
Are you pregnant, trying to become pregnant, or breastfeeding?

Tirzepatide (Zepbound®) has not been studied in pregnancy and may pose risks to the fetus. If you are or become pregnant, stop the medication immediately and contact Skinn-ee Bees, LLC for guidance. Additional product safety information is available through Eli Lilly.

Eli Lilly & Co. Medical Information

Phone: 1-800-245-8395

Website: lillymedical.com

5. Medication Information

The following information is provided for your reference.

Tirzepatide (Zepbound®) is a once-weekly injectable medication licensed by Eli Lilly and Company. Dose strengths range from 2.5 mg up to 15 mg per 0.5 mL single-use pen. A typical maintenance dose is 7.5 mg weekly, but your provider may adjust dosing based on how you respond and tolerate the treatment.

Refrigerate the medication immediately upon receipt (36°F–46°F / 2°C–8°C). If refrigeration is unavailable, Zepbound® may be stored at room temperature (68°F–77°F / 20°C–25°C) for up to 21 days. Protect from heat, light, and freezing. For questions about the formulation, contact Eli Lilly Medical Information at 1-800-245-8395 and refrigerate your medication upon delivery.

6. Informed Consent

Review the full consent information below, then acknowledge your understanding and agreement.

By signing this informed consent, you acknowledge that your Skinn-ee Bees provider has reviewed your medical history, answered your questions about Tirzepatide (Zepbound®), and discussed alternative treatment options. You understand that this medication is used for weight management and metabolic health support and that results vary between individuals.

Common side effects

  • Nausea, vomiting, or decreased appetite
  • Diarrhea, constipation, or abdominal discomfort
  • Heartburn, belching, or bloating
  • Injection-site redness or mild irritation

Rare but serious risks

  • Gallbladder issues, including gallstones or inflammation
  • Pancreatitis (sudden severe abdominal or back pain, fever)
  • Hair thinning or hair loss
  • Thyroid C-cell tumors (seen in rodent studies; human risk unknown)

Seek emergency care or call 911 if you experience signs of an allergic reaction such as rash, hives, wheezing, swelling of the face or throat, or difficulty breathing.

If you have diabetes or take medications that lower blood sugar, monitor your glucose closely. Low blood sugar (hypoglycemia) may cause shakiness, dizziness, confusion, sweating, or a rapid heartbeat. Treat promptly with fast-acting carbohydrates and notify your provider.

Tele-health check-ins or secure messaging touchpoints are required prior to refills. Medication will be dispensed only after payment is received and verified by Skinn-ee Bees, LLC.

Store Tirzepatide (Zepbound®) in the refrigerator. If needed, it may remain at room temperature for up to 21 days. Do not freeze, shake, or expose the pen to direct sunlight. Discard any pen that has been frozen or stored improperly.

I have read and understand the risks and benefits of Tirzepatide (Zepbound®) and consent to treatment through Skinn-ee Bees, LLC.

I have read and understand the risks and benefits of Tirzepatide (Zepbound®) and consent to treatment through Skinn-ee Bees, LLC.

Typing your name serves as your electronic signature. A stylus capture can be collected during your visit if required.

By selecting Submit, your responses will be securely transmitted to Skinn-ee Bees, LLC. A confirmation message and provider notification will be generated once processing is complete.