Medical Weight Loss Inquiry

Medical Weight Loss Inquiry
Our Medical Weight loss program is membership-based. Our monthly fee for the program starts at $299/month ($299/month for our low-dose (up to 1.325mg weekly dose) Semaglutide therapy, $399/month for higher doses (1.5mg and higher weekly doses) Semaglutide therapy. Tirzepatide costs $499/month for low-dose therapy (up to 8.5mg weekly dose) and cost varies for higher doses.) We do not use health insurance to cover for the cost of visits and/or the medication. Please complete the form below if you still want to proceed.

The monthly fee is inclusive of all of your appointments and medications. Additionally, you also receive the following wellness services for FREE:

- Four (15-min) sessions every month toward any combination: Dry Float Therapy, Hydromassage therapy, & Vibroacoustic therapy.

- Members can add additional sessions for only $19 each.

- 10% off any IV Vitamin therapy (Including IV weight loss drip therapy)
What's your Full Name?*

First NameLast Name
Date of Birth*

MonthDayYear
We are only able to treat those over the age of 18
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Legal Address*
We can only provide services to patients in Washington State
Assigned sex at birth*

MaleFemale
What are your preferred pronouns?

She/Her/HersHe/Hims/HisThey/Them/TheirsOther
What is your current weight?*
What is your height?*
What is your health insurance? (If applicable)
Type "None" if you do not have health insurance.
Tell us what you struggle with?*

I believe my metabolism is slowI eat a lot when I'm stressed outMy medications are making me gain weightI'm always hungryI eat a lot mostly at nightCravingsI don't/can't exercise adequatelyI'm not really sureOther
What have you tried in the past to lose weight?*

DietWeight loss MedicationsSurgeryI'm not really sureOther
What medication(s) for weight loss have you tried in the past? *
What medication(s) are you currently taking?*
Please include dose and frequency. Type "None" if you are not taking any medications currently.
What weight loss medications are you interested in?*

SemaglutideLiraglutideTirzepatideMetforminPhentermineTopiramateBupropionNaltrexoneOther
Does any of the following apply to you?*

Currently pregnantCurrently BreastfeedingActive eating disorderActive or history of substance abuseTrying to be pregnantCurrently being treated for cancerActive gallbladder diseaseHistory of PancreatitisHistory of Medullary Thyroid cancerHistory of Multiple Endocrine NeoplasiaType 1 Diabetes MellitusType 2 Diabetes MellitusBariatric SurgeryKidney disease / Renal impairmentNone of the AboveOther
How do you prefer your appointment?*

TelehealthIn-Person
Which location do you prefer to visit for in-person appointments?*

Tacoma (2115 S 56th St, Ste 304, Tacoma, WA 98409)Lacey (655 Golf Club Pl SE, Ste A, Lacey, WA 98503)
Please tell us your preferred time and days of the week for your appointment?*
Anything else you want us to know?
How did you hear about us?*

Google Search / Google AdSocial Media (FB, Instagram)Referral form other providers or therapistsReferral by an All Good patientWord of MouthOther
Submitting this form DOES NOT guarantee an appointment. Your request has to be reviewed and approved within 1-3 days. Once approved, we will reach out to you to schedule your new patient intake appointment. (If we can't get a hold of you after numerous attempts, we are going to assume that you are no longer interested to proceed and will have to cancel the request)
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