GLP-1 Prescription Questionnaire

WELCOME

GLP-1 Prescription Questionnaire (Weight Loss Focus)
Choose Your medications*
Additional Message

What was your gender at birth ?*
This will help us understand your body complexity so we can assess you better.

What is your current height?*
Feet*
Inches*
centimeter (cm)*

What is your current weight?*
pound weight (lbs)*
kilogram (kg)*

What is your desired weight?*
pound weight (lbs)*
kilogram (kg)*

Have you been diagnosed with obesity or any other weight-related health conditions?*

YesNo
Please specify*

Have you tried other weight loss medications or programs before?*

YesNo
what was your experience?*

Are you currently taking any medications for weight loss or any other chronic conditions?*

YesNo
Please list them*

Are you taking any over-the-counter supplements or herbal products to aid in weight loss?*

YesNo
Please list them*

Concerns About Side Effects - Have you experienced nausea, vomiting, or gastrointestinal issues with other medications?*

YesNo

How many alcoholic beverages do you consume per week?*

None1-23-56+

Have you been diagnosed with any kidney or liver issues?*

YesNo
Please provide details*

What is your date of birth ?*

MonthDayYear
Our bodies and needs change with age (think hormones), so we’ll need to know when you were born.

What is your email? *
example@example.com

What is your phone number?*
Please enter a valid ten-digit phone number. The number cannot start with zero or one . We’ll contact you within 24 hours on this phone number.

What would you like to receive your medication?*

Home DeliveryPick up at Botox&Fillers Lab
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2 (optional)

CityState

Zip Code
Should be Empty: