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COMPOUNDED GLP-1 SEMAGLUTIDE / TIRZEPATIDE PRE SCREENING FORM PLEASE ENTER THE FOLLOWING:Patient Name:(Required) First Last Patient Gender:(Required) Male Female Patient Date of Birth:(Required) MM slash DD slash YYYY Patient Race:(Required)Select One:CaucasianBlack or African AmericanOtherPatient Ethnicity:(Required)Select One:Not Hispanic or LatinoHispanic or LatinoPatient Address:(Required) Street Address Apartment, Suite, or Floor City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S