[Pure Wellness] Semaglutide

1
What was your gender at birth?* This field is required.This will help us understand your body complexity so we can assess you better.
Male
Female
Other
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Weight and Height* This field is required.
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Based on your current weight, with Puerwellness you can lose your weight*Projection based on weight loss outcomes associated with semaglutide clinical trial (PMID: 36121652). Individual results may vary and are closely related to the treatment plan our providers will develop for you.
4
What goals are you looking to accomplish?
Lose weight
Look better
Improve general health
Improve confidence
Improve energy
5
Have you ever been on Semaglutide or Tirzepatide?
Semaglutide
Tirzepatide
Both
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Thanks for sharing! We’re here to help.We’re proud to uphold high standards to help thousands of Americans achieve their wellness goals every month
7
What have you tried in the past?
Exercise
Intermittent fasting
Dieting
Medical weight loss program
Weight loss Suplements
8
How often do you exercise currently?This can be a 20 minute walk or something more intensive.
I rarely exercise
I exercise almost every day
I exercise 2-3 times per week
9
Please check the boxes next to any of the following conditions that you have been diagnosed with.This information will help us in providing the most effective care and treatment recommendations.
High cholesterol
High blood pressure
Fatty liver disease
Pre-diabetes / Type 2 Diabetes / Hba1c above 5.7
None of the above
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What is your date of birth?* This field is required.Our bodies and needs change with age (think hormones), so we'll need to know when you were born.
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Day
11
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Full Name* This field is required.
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Important Medication Warnings* This field is required.By checking the box below, I acknowledge that I have read and understood the important medication warnings provided. I agree to follow the guidelines for safe and effective use of the medication.
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Patient Acknowledgement & SignatureBy signing below, you confirm that you have reviewed the important medication warnings, understand the potential risks and instructions, and agree to comply with the safe use guidelines.
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