Weight Loss Visit

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    Location Requirement Notice
    In accordance with telemedicine regulations, you must be physically located in a state where our providers are licensed at the time you complete and submit this visit form.

    Residency in a licensed state is not required. Patients may complete visits while temporarily present in a licensed state (e.g., travel or vacation). When clinically appropriate, prescriptions may be sent to a pharmacy in your home state.

    If you are not currently physically located in a licensed state, you are not eligible to proceed at this time. Please complete this visit once you are physically present in a licensed state.

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Terms of Service

  • *

  • Advance Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

  • You should not use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe of unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • Are you experiencing an emergency? If you are experiencing an emergency, call 911 or go to an emergency room immediately.*
  • Which type of visit is this for?*
  • Do you exercise?*
  • How many days per week do you exercise?*
  • How long do you exercise for?*
  • What do you do for exercise? (Select ALL that apply)*
  • Are you on a diet?*
  • Which type of diet are you on? (Select ALL that apply)*
  • On average, how many calories do you eat per day?*
  • How long have you been dieting/exercising for?*
  • Have you ever tried weight loss medications before?*
  • Which weight loss medications have you previously tried? (Select ALL that apply)*
  • Were you successful with the weight loss medication?*
  • Are you currently taking a medication for weight loss?*
  • Which weight loss medication(s) are you currently taking? (Select ALL that apply)*
  • Which weight loss medication do you need a refill on?*
  • Due to this medication no longer being on the FDA shortage list, you must have a medical necessity to use the compounded option instead of the brand-name medication. Please select the reason(s) why you require/request the compounded GLP-1 or GLP1/GIP medication. (Select ALL that apply).*
  • Which type of Wegovy are you on?
  • When was your last Wegovy dose?*
  • When was your last injection?*
  • Would you like to increase to the next dose?*
  • Are you experiencing any adverse side effects with this medication?*
  • Which adverse side effects are you experiencing? (Select ALL that apply)*
  • Have you ever been diagnosed with any of the following? (Select ALL that apply)*
  • Do you have a personal or family history of Medullary Thyroid Cancer (MTC) or Multiple Endocrine Neoplasia Type 2 (MEN2)?*
  • Is there any chance you could be pregnant?*
  • Are you breastfeeding?*
  • When did you last have lab work done?*
  • Were your lab results normal?*
  • Are you able to upload an image of your lab results?*
  • Are you currently taking any medications?*
  • Are you taking any new medications since your last visit?*
  • Do you have any medication allergies?*
  • Any changes to your medical history since your last visit?*
  • How has your medical history changed? (Select ALL that apply)*
  • Do you have or are you able to take a full body image?*
  • Which weight loss medication would you like to try?*
  • Due to this medication no longer being on the FDA shortage list, you must have a medical necessity to use the compounded option instead of the brand name medication. Please select the reason(s) you require or request the compounded GLP-1 or GLP/GIP medication. (Select ALL that apply).*
  • Does your insurance cover weight loss medication?*
  • Tell us what's most important to you:*

  • Medication Options

  • Semaglutide - Starting Dose
  • Semaglutide - 0.5mg Dose
  • Semaglutide - 1mg Dose
  • Semaglutide - 1.5mg - 2mg Dose
  • Semaglutide - 2.5mg Dose
  • Tirzepatide - Starting Dose
  • Tirzepatide - 5mg Dose
  • Tirzepatide - 7.5mg Dose
  • Tirzepatide - 10mg Dose
  • Tirzepatide - 12.5mg Dose
  • Tirzepatide - 15mg Dose
  • Liraglutide
  • Bupropion/Naltrexone/B12 Compounded Capsules

  • COMPOUNDED MEDICATION AND ADDITIONAL MEDICATION ADD-ON OPTIONS

  • Would you like to add any of the following medications?
  • Have you used Zofran (Ondansetron) before?*
  • Did you have any adverse reactions when using Zofran (Ondansetron)?*
  • Have you ever been diagnosed with long QT syndrome/prolongation?*
  • Payment method*
  • Is there any additional information you would like to share?*

  • Pharmacy Information

  • Shipping Information

    Please enter and verify the address where you would like your medication shipped to.

  • If Omnia's providers determine that weight loss medications are not appropriate, you will not be charged for the visit (or you will be refunded).

    Once the visit is reviewed and completed, there will be no refunds for the visit.

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