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.
Cancelof
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

Total

$0.00

Credit Card

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Patient Intake Form

Personal Information

Medical History

Identification Verification

Payment Information

Credit Card