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  • 2025 Weight Loss Form

    2025 Weight Loss Form

    GLP1 / GIP / Lipo B/C | ALL OPTIONS |
  •  - -
  • Gender*
  • Format: (000) 000-0000.
  • If your BMI is UNDER 30. You MUST have one of these in order to qualify:*
  • Have you ever been diagnosed with, or do you currently have, any of the following conditions?*
  • Do you have any chronic medical conditions?*
  • If you are female, are you currently using any form of birth control?"*
  • [IMPORTANT] Are you currently taking ANY PRESCRIBED medications or supplements?*
  • Have you ever had surgery?*
  • Do you have any allergies?*
  • Are you currently pregnant or trying to become pregnant?*
  • Have you ever experienced any of these symptoms?*
  • Have you been diagnosed with a mental health condition?*
  • Do you currently have any desire to harm yourself or others?*
  • Do you smoke cigarettes?*
  • Do you have any medical conditions or chronic diseases?*
  • Have you or a family member ever been diagnosed with any of the following conditions?*
  • Have you taken any of the following recreational drugs in the past 6 months?*
  • Has a close family member under the age of 65 passed away unexpectedly due to a possible cardiac event?*
  • Are you currently or have you ever taken a GLP-1 medication? (GLP-1s can include compounded semaglutide, compounded tirzepatide, Ozempic, Wegovy, Mounjaro and Zepbound)*
  • How often do you consume 5 or more alcoholic drinks in one occasion?*
  • What is your average resting heart rate? (You can find your average resting heart rate if you own a wearable like an Apple Watch)*
  • Do you exercise regularly?*
  • Do you tend to get side effects from new medication?*
  • Please rate how you feel about potentially experiencing nausea and an upset stomach.*

  • Read Me

    Please upload a photo ID below. If you don’t have lab results, you can skip that step for now.

  • Consent:
    By submitting this form, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used to assist in my medical evaluation and treatment with Halevy Medical Health or other Medical Facility.

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    BIG SAVINGS WITH A 3 MONTH SUPPLY OF SEMAGLUTIDE OR TIRZEPATIDE
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    Semaglutide [Compounded] [ ANY DOSE ] Product Image
    Semaglutide [Compounded] [ ANY DOSE ]

    GLP-1 | Once weekly injection | Up to 15% weight loss | 

    $399.00
      
    Tirzepatide [Compounded] (Up to 7.5mg dose) [ STARTER DOSES ] Product Image
    Tirzepatide [Compounded] (Up to 7.5mg dose) [ STARTER DOSES ]

    GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss | 

    $499.00
      
    Tirzepatide [Compounded] (10mg or 12mg) [HIGH DOSES] Product Image
    Tirzepatide [Compounded] (10mg or 12mg) [HIGH DOSES]

    GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss | 

    $550.00
      
    Tirzepatide [Compounded] (15MG) [ MAX DOSE ] Product Image
    Tirzepatide [Compounded] (15MG) [ MAX DOSE ]

    GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss | 

    $599.00
      
    Ozempic BRAND Product Image
    Ozempic BRAND

    GLP-1 | Once weekly injection | Up to 15% weight loss | 

    $950.00
      
    Wegovy BRAND Product Image
    Wegovy BRAND

    GLP-1 | Once weekly injection | Up to 15% weight loss | 

    $1,300.00
      
    Mounjaro BRAND Product Image
    Mounjaro BRAND

    GLP-1 + GIP - Once weekly injection | Up to 22.9% weight loss |

    $1,050.00
      
    Zepbound BRAND Product Image
    Zepbound BRAND

    GLP-1 + GIP | Once weekly injection | Up to 22.9% weight loss | 

    $1,050.00
      
    Lipo (Addon) Product Image
    Lipo (Addon)

    Contains methionine and choline, which support fat metabolism by aiding liver function and the breakdown of stored fat. This can help enhance weight loss, improve energy levels, and support liver health when combined with a proper diet and exercise regimen.

    $45.00
      
    Lipo-B (Addon) Product Image
    Lipo-B (Addon)

    Contains methionine and choline to support fat metabolism and liver function, plus cyanocobalamin (Vitamin B12) to boost energy production and red blood cell formation. This combination helps enhance fat breakdown, improve energy levels, and support overall metabolic function when used alongside a healthy diet and exercise.

    $55.00
      
    Lipo-C (Addon) Product Image
    Lipo-C (Addon)

    Contains methionine and choline to support fat metabolism and liver function, similar to Lipo and Lipo-B, with the added benefit of carnitine to enhance fat burning and energy production. In addition, it includes dexpanthenol (Vitamin B5), which supports cellular metabolism and helps convert fats and carbohydrates into energy more efficiently.

    $65.00
      
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