Radiate Health and Wellness Weight Loss Program
www.radiatehealth.net
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Form
Name
First Name
Last Name
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Email
example@example.com
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What is your date of birth?
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Phone Number
Please enter a valid phone number.
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How did you hear about me?
Facebook
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Referral
I know you IRL friend!
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Starting Height and Weight
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Do you have a history of Medullary Thyroid Cancer, Pancreatitis or Gastroparesis
Yes
No
I have no idea what you just said
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Do you have any allergies? If so please list:
Have you had routine labwork completed in the last 6 months?
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The Radiate Wellness Weight Loss Membership is $99/month. This includes your medication management, basic labs and follow up appointments. Medications are prescribed and ordered as needed. Medication options include injectable compounded GLP1 and GLP1/GIP and oral medications. This is a telehealth program, appointments are virtual and in eastern time. This is only available to TN and GA residents. (This does not enroll you in the program, you will receive an email with next steps.)
Sounds good, I'm ready!
Not right now, thank you!
Please verify that you are human
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What is your current dose of Semaglutide? (If not applicable leave blank)
What is your current dose of Tirzepatide? (If not applicable leave blank)
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