Form
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Hello, Welcome to Wiley Family Health were we are dedicated in helping you reach your health care and weight loss goals! Complete the following form to get your weight loss plan started today!
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Appointment
Have you been diagnosed with obesity or overweight with at least one weight-related comorbidity (hypertension, diabetes, etc.)?
Yes
No
Have you tried other weight management strategies such as diet, exercise, andbehavioral modifications without sufficient success?
Yes
No
Are you currently taking any medications or supplements for weight loss or otherconditions?
Yes
No
Have you ever been diagnosed with type 2 diabetes? If so, are you taking anymedications for it?
Yes
No
Do you have a history of pancreatitis or pancreatic disease?
Yes
No
Do you have any history of thyroid disease or thyroid cancer, either personal or in your family?
Yes
No
Have you ever had an allergic reaction to semaglutide or any other GLP-1 receptor agonists?
Yes
No
Are you pregnant, planning to become pregnant, or breastfeeding?
Yes
No
Do you have any history of gastrointestinal disorders, such as gastroparesis orinflammatory bowel disease?
Yes
No
Do you have a history of kidney disease or impaired kidney function?
Yes
No
Do you have any history of heart disease or cardiovascular issues?
Yes
No
Are you willing and able to adhere to the recommended dosing and administrationguidelines for semaglutide?
Yes
No
Current Height
Current Weight
Goal Weight
Submit
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