Medical Weight Loss Intake

Patient Intake Form

Please fill out the following information to complete your patient intake and payment information.
Personal Information
Legal First and Last Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Gender at Birth*

MaleFemaleOther
Current Weight and Height*
Do you have any of the following diagnosis (select all that apply)*

High CholesterolNon-Alcoholic Fatty Liver DiseaseHigh Blood Pressure (Hypertension)Pre-Diabetes/Type 2 Diabetes/HbA1c above 5.7PCOSMetabolic SyndromeCardiovascular DiseaseOsteoarthritisObstructive Sleep ApneaNone of the Above
Do you have any of the following diagnosis (select all that apply) *Note these may be contraindicated for GLP's*

Medullary Thyroid Cancer (MTC) or a family history of MTC or multiple endocrine neoplasia Type 2Any CancerMultiple Endocrine Neoplasia Syndrome Type 2 (MEN 2)Serious allergic reaction to Semaglutide or Tirzepitide or compounded componentsActive CancerActive Drug or Alcohol MisuseEating DisordersBipolar DisorderSchizophreniaPancreatitisDiabetes Mellitus Type 1 or Insulin Dependent Type 2Any Liver or Kidney DiseaseActive Gallbladder DiseaseChronic or Persistent Hypoglycemia with ranges < 60 mg/dlPregnant or Planning to Become Pregnant in the Next 2 MonthsNone of the Above
Weight Loss Goals*

Lose 1-20lbs for goodLose 21-50lbs for goodLose over 50 for goodMaintain my healthy weightNone of the aboveOther
What weight loss initiatives have you tried in the past? (select all that apply)*

ExerciseDietingWeight-loss SupplementsIntermittent FastingOther GLP1'sOther
Identification Verification
Please upload a government issued form of ID (Driver's License, Passport, etc.)*

Please be sure your full name and photo are easily visible along with your ID number and the State Issued.
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Payment Information

If you have any specific questions prior to payment and submission please reach out to ridgemedspa@gmail.com or go to https://www.ridgemedspa.com/contact/

Ridge Med Spa & Suites Medical Weight Loss- Monthly Subscription*

Monthly Medical Weight Loss Product Image

Monthly Medical Weight LossYour subscription includes: Consultation, Medication, and Shipping to your home. The cost does not increase when your dosage increases!

$299.00 for each month

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Credit Card

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Patient Intake Form

Personal Information

Medical History

Identification Verification

Payment Information

Credit Card