Name*

Today's Date*

Date of Birth*

Phone number*

Home address*

Email*

Please state your Emergency contact's name, relationship, and phone number*

Preferred contact method*

How did you hear about us?*

What is your main goal?*

If your main goal is weight loss, what have you tried in the past?

Have you used Ozempic, Wegovy, Mounjaro, or Zepbound before?*

Which GLPs have you used in the past?*

What is your current Height? *

What is your current weight?*

Do you drink Alcohol? If yes, please state average drinks per week. *

Do you use Tobacco or Marijuana? *

Please provide a list of the medications that you are currently taking. If none, state N/A*

Please provide a list of the Vitamins and Supplements that you are currently taking. If none, state N/A*

Do you have any drug allergies or Sensitivities? If none state N/A*

Have you had any surgeries? If none, please state N/A.*

Do you have any of the following? (select all that apply)*

Please list any medical condition that was not mentioned above. If none, state N/A*

Please give us a current snapshot of your lifestyle including Diet, Exercise, Sleep quality and Stress levels*

I understand this is a medical weight loss program and does not guarantee results. I agree to be contacted for scheduling and follow-up*

Do you have medical insurance? If so, please let us know and if we need to order labs; they may be covered by your carrier. *