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Preferred method of communication: Email or Text?

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Patient Health Information

Reason for Medication (detailed is better)

Have you ever had an allergic reaction to tirzepatide, Mounjaro, or another GLP-1 agonist diabetes medication?

Yes No

Do you have a personal or family history of thyroid cancer?

Yes No

Have you been diagnosed with gallbladder, pancreas or kidney problems?

Yes No

Have you ever had thoughts of suicide or self harm?

Yes No

Are you planning on having surgery in the near future?

Yes No

Are you pregnant or planning to get pregnant in the next two months?

Yes No

What is your current weight (in pounds)?

What is your current height? ft

Controlled substances cannot be prescribed through Moongate Medical

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After you submit your request, a licensed medical provider will review your information. You will be notified by email/text when that provider has reviewed your request and, if appropriate, made care recommendations.

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826 E 12300 S Suite 4, Draper, UT 84020

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Phone: 801-615-3675

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