Semaglutide Qualification

Semaglutide Qualification Form

Please complete all fields marked with a star. We will contact you if you qualify for this breakthrough treatment method.
Name*

First NameLast Name
Gender*

FemaleMale
Mobile Phone*
Please enter a valid mobile phone number.
Email Address*
example@example.com
Preferred Contact Method*

Text MessageEmailPhone Call
Clinic Location*

BakersfieldClovis
Is $350 per month within your budget for Semaglutide weight loss?*

YesNo
Semaglutide Qualification
Height (ft)*
Height (in)*
Height Inches
Weight (lbs)*
BMI
BMI: {bmi9} = Low

Based on your weight and height, you seem to be in the "Underweight" range, which disqualifies you from Semaglutide and our medical weight loss program. It's a good problem to have.
BMI: {bmi9} = Normal

Congratulations, you are in a normal and healthy weight range. Although Semaglutide is not "medically necessary", you may still be able to get started on one of our programs under "off-label" use.
BMI: {bmi9} = High

Based on your Body Mass Index (BMI), you are considered "overweight". Semaglutide may be medically indicated if you have one or more weight related illnesses, including diabetes, high blood pressure and / or high cholesterol. Please complete the next question below. Even if you have no medical problem, you may get started on one of our programs under "off label" use.
BMI: {bmi9} = Very High

Based on your Body Mass Index (BMI), your are in the "obesity" range, which qualifies you for our Semaglutide weight loss program.
Do you have any of the following (check all that apply or NONE)?*

NONEAsthmaDiabetesHeart AttackHeart DiseaseHigh CholesterolHypertension
Illness Score
Qualifies for Semaglutide?

NOYES
Lead Source
Should be Empty:

Semaglutide Qualification Form

Semaglutide Qualification