Patient Intake Form

Welcome to Anava!

Ready to glow?

This secure intake helps us learn about your goals, health history, and the treatments you’re considering. It only takes 2–4 minutes.

After submitting, we’ll reach out via our secure Spruce app to confirm your selection and guide you through next steps. A licensed provider will review your intake to ensure the treatment is safe and appropriate for you.

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Which state do you currently reside in? (Note: At this time, we only serve select states for prescription eligibility. We will add more states soon.)

Which product(s) are you interested in?

Untitled checkboxes field

• Tirzepatide (Compounded)

• Tirzepatide + B3 (Compounded)

• Semaglutide (Compounded)

• Semaglutide + B3 (Compounded)

• Semaglutide + B12 (Compounded)

• Liraglutide (Compounded)

• Peptides (Bioboost, NAD+, etc.)

• Hormone Replacement Therapy

• Female Sexual Wellness

• Male Sexual Wellness

Please confirm any plans you’re interested in below.

(You’ll be able to discuss these selections with your provider before anything is finalized.)

Is there a special promo from our website that you’re interested in?

(If no, skip & continue to plan selection below.)

Are you interested in Anava Essentials GLP-1 plans?
(Select one IF yes.)

Are you interested in Anava Core GLP-1 plans?
(Select one IF yes.)

Are you interested in any wellness products?
(Select one IF yes.)

Have you taken any of the products you’re selecting above?
(If yes, please list the medication, your current dose, and whether you’d like to titrate up or stay on the same dose.)

Why are you requesting a compounded medication? (Required)

(Compounded medications are typically considered when commercial options are not accessible, tolerated, or appropriate for a patient’s needs.)

First and Last Name (Required)

Date of Birth (Required)

Phone Number & Email

Please include city, street, state, zip code, and apartment number, if applicable.

Height & Weight (lbs & in.)

Goal Weight (if applicable)

Medical Screening + Consent

Have you ever been diagnosed with any of the following?

• Medullary Thyroid Cancer (MTC)

• MEN2 (Multiple Endocrine Neoplasia Type 2)

• Gallbladder disease

• Kidney or liver disease

• Diabetes (Type 1 or Type 2)

• Pregnant or breastfeeding

• None of the above

Are you currently taking any medications?

Yes

If yes, please list your current medications:

Do you have any allergies to medications or injections?

Yes

If yes, please list your allergies:

Is there anything important that you want the provider and/or Anava Health to know?

Where did you hear about us?

CONSENT & ACKNOWLEDGEMENT

• I understand that treatments include custom-compounded medications not evaluated by the FDA.

• I am at least 18 years old and completing this intake truthfully and voluntarily.

• I understand I may be asked to provide valid photo ID to verify my identity or age.

• I understand this is a self-pay program and insurance will not be billed for services or prescriptions.

• I understand compounded prescriptions are used only when commercial options are not accessible, tolerated, or appropriate for my needs.

• I consent to secure communication via Spruce, email, or SMS for appointment and prescription updates.

• I understand that GLP-1 therapies (such as Semaglutide or Tirzepatide) may cause side effects including nausea, bloating, fatigue, or appetite changes.

• I understand that peptides, hormone therapies, and wellness treatments may have varying results and are not intended to diagnose, treat, or cure any disease.

• I understand that adverse reactions may occur with any medication, and I agree to report any concerning or unexpected symptoms to my provider immediately.