Medical Weight-loss Survey

Health Optimization Packages

Teylar Arroyo, NP | Optimum Wellness + Health
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Sex*
Current Age*
What treatment are you most interested with Teylar Arroyo, NP at Optimum Wellness and Health*

Metabolic Reset (FlexDose Tirzepatide)Metabolic Reset (FlexDose Semaglutide)Metabolic Reset (FDA Approved Zepbound)Woman's MidLife Reset (progesterone/estrogen)Anti-Aging Peptides (NAD+)Men's MidLife Reset (testosterone)Metabolic + MidLife ResetThe Coaching Package, Health and LifeStyleOther
How ready are you to start your medical weight-loss journey?

Very ready, have researched and ready to make this happenActively researching but interestedNot super interested, just seeing if I qualify
What are the most important factors to you when deciding on a wellness program?

PriceThe right provider/coachA comprehensive tailored longterm programFDA Approved options (not compound)Ease of AccessVirtual follow up optionsIn Person Follow up optionsA flexible follow up plan (virtual and in person)Other (Please note in free text box at the bottom of this page)
What is your BMI range, Calculate to the right*

26.9 and below27-3030 or above
Calculate your BMI
Do you or a blood related family member have a history of medullary thyroid cancer or Multiple Endocrine Neoplasia (MEN) syndrome*

YesNo
Currently breastfeeding, pregnant, or planning to become pregnant?

YesNoWould like to lose weight to be able to conceive
Currently being treated or investigated for cancer?*

YesNo
Have you even been diagnosed with Breast Cancer?*

YesNo
Do you have an active eating disorder?*

YesNo
Active gallbladder disease?*

YesNo
Active substance abuse or dependency*

YesNo
Type I Diabetes*

YesNo
Bariatric surgery within the past 18 months*

YesNo
Pancreatitis within the past 6 months or a history of pancreatitis caused by taking a GLP-1*

YesNo
Are you located in Florida?*

YesNo
Have you ever been on a GLP1/GIP or Hormone Therapy?*

YesNo
If yes to above, Explain your previous treatments with GLP1/GIP or Hormone therapy
Any other comments? Do you have any questions or concerns you would like to describe below?
After submission, I will contact you via the email provided, to see if you have any further questions.

My programs usually start with a no obligation comprehensive consult, labwork and review via zoom to see which program is right for you.

Patient success is rooted in transparency, shared decision making and a longterm provider-patient relationship

Our steps for success
1. Free Strategy Call
2. No obligation Comprehensive consult with labwork and review, can apply $150 of this fee to any 2-3 month program!
3. Choose Program, purchase package and get started. If medications are part of your package, they will arrive within 3-5 business days excluding weekends.
4. Follow up and support with me along the way
5. Repeat labwork in 3-6 months
6. Longterm success and low dose maintainance is the goal, we will work together to meet goals and keep you there.
Phone

772-206-2028 Call/Text

Email

Info@optimumwh.com
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Health Optimization Packages