Weight Loss Intake Form

Weight Loss Intake Form
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Gender*
Patient E-Mail*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Contact

First NameLast Name
Emergency Phone Number
Please enter a valid phone number.
Referred by:

First NameLast Name
Patient Height (inches)*
Patient Weight (lbs)*
What are your weight loss goals?*
Patient Medical History
Do you have any of the following

HypertensionDiabetesHigh cholesterolThyroid diseaseCongestive Heart FailureSleep apneaAnemiaCancerAnemiaDepressionStrokeUlcerHeart diseaseArthritisKidney diseaseLiver disease
Other illnesses:
Please list all current medications *
Please list all Allergies*
Please list all family illness
Healthy & Unhealthy Habits
Exercise*

Never1-2 days3-4 days5+ days
Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
PROGRAM AND PRICE LIST
PHYSICIAN CONSULTATION: $100
LIPOTROPIC PLUS/B12- $50/ injection ($150/month)
SEMIGLUTIDE (WEGOVY/B6) - ($400/month)
TIRZEPATIDE (MOUNJARO) - ($500/Month) 2.5mg, 5mg, 7.5mg
TIRZEPATIDE (MOUNJARO)- ($650/month) 10mg, 12.5mg
TIREZEPATIDE (MOUNJARO)- ($800/month) 15mg
BELLA TABLETS - $150/MONTH (30 tablets)

IV INFUSIONS

Normal Saline 1L : $100
Meyers Cocktail IV: $180
Immunity Cocktail IV: $200
Migraine Cocktail IV: $200
Glutathione 1500mg/Vitamin C 1500mg : $150
Glutathione 3000mg/Vitamin C 3000mg : $300
NAD+ 250mg : $250
NAD+ 500mg: $500
Preferred consultation Time*
All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician/provider/staff/volunteers, I accept full liability from any consequences arising there from. *

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Weight Loss Intake Form

Patient Medical History

Healthy & Unhealthy Habits