Medical Weight-loss Survey

Medical Weight-loss Survey

Please read the responses to questions in the gray boxes to the right when hovering over questions
Name*

First NameLast Name
Email*
example@example.com
Phone Number
Please enter a valid phone number.
What treatment are you most interested in for Medical weight-loss*

Tirzepatide (Zepbound)Semaglutide (Wegovy)PhentermineVitamin B12 InjectionsOther
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
Please indicate your age*

0-1718-2121+
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
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
If you answered "YES" to any of the above, you may not qualify for treatment. However if you would still like to discuss your goals and medical history please continue to submit this form and it will direct you to a free consult scheduling link.
Are you located in Florida?*

YesNo
Do you have any questions or concerns you would like to describe below?
A little bit about our program

Our weightloss program includes
- Medical evaluation
- Medication and supply costs direct to you, or in person pick up
- Medication sourced from FDA accredited compounding pharmacy with proven patient results and product quality!
  - Check out our Google reviews HERE!
  - Before and after photos HERE (scroll down to section)
- Dietary/nutritional guidance with an assigned care plan and use of our medical app Healthie
- Symptom management with RX if needed to your local preferred pharmacy
- Unlimited communciation with our board certified providers
- Semaglutide packages starting at 250 a month
- Tirzepatide packages starting at 400 a month
If you feel you would qualify and would like to take the next step in starting therapy schedule follow the link below or submit the jot form to be re-directed to our calander

Link to our calendar

Once you schedule, you will be sent an invitation email from our Healthie Application. Please accept the invite and download the app to facilitate your appointments.

Please feel free to contact us if you have any questions or need help!

info@optimumwh.com or 772-206-2028
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