Start Your Personalized Weight Loss Evaluation
🔒 This form is HIPAA-compliant. Your data is encrypted and kept confidential.
Step 1: Tell Us About You
What’s your full name?
First Name
Last Name
When were you born?
-
Month
-
Day
Year
Date
Sex Assigned at Birth
Please Select
Male
Female
N/A
Gender
What’s your email address?
example@example.com
What’s your cell phone number?
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred consultation type:
Virtual via Telehealth
In-person (San Antonio)
Either
Back
Next
Step 2: Health Metrics & BMI Calculation
We’ll use your height and weight to calculate your Body Mass Index (BMI), which helps us determine your eligibility for GLP-1 treatment. This step takes just a few seconds.
Height (feet)
Enter your height in full feet only (e.g., 5 if you are 5'7")
Additional Inches
Enter the remaining inches above your full feet (e.g., 7 if you are 5'7")
Current Weight (lbs)
Enter your current body weight in pounds.
Your BMI (Body Mass Index)
This number is automatically calculated based on your height and weight. A BMI of 27+ is typically required for eligibility.
Medical History
Please check all current or past medical conditions that apply:
Type 1 Diabetes
Type 2 Diabetes
Prediabetes
Hypoglycemia (low blood sugar)
Hyperthyroidism
Hypothyroidism
Thyroid Cancer
Family history of thyroid cancer
Pancreatitis
Pancreatic cancer
Gallbladder disease
History of gallbladder removal
Liver disease (e.g., NAFLD)
Kidney disease (Stage 3 or greater)
Heart disease or cardiovascular conditions
High blood pressure (Hypertension)
High cholesterol or triglycerides (Dyslipidemia)
Metabolic Syndrome
PCOS (Polycystic Ovary Syndrome)
Sleep apnea
Osteoarthritis
GERD (acid reflux)
Gastrointestinal paralysis (Gastroparesis)
Anorexia or Bulimia
Depression or Anxiety
Chronic fatigue or low energy
Currently taking corticosteroids or antipsychotics
Currently pregnant or breastfeeding
Using GLP-1 medications (e.g., Ozempic, Wegovy, Mounjaro, Zepbound)
None of the above
Other condition
List All Current Medications (including dosage)
Please list all prescription and over-the-counter medications you are currently taking. Include dosage, frequency, and route (e.g., oral, injection).
Lifestyle & Nutrition Assessment
Tell us about your typical eating habits, activity level, and any lifestyle changes you’ve recently made or plan to make.
Previous Weight Loss Attempt
Yes
No
Consent and Acknowledgement (confirming understanding of GLP-1 treatments)
Yes
No
Back
Next
Medical Evaluation Fee – GLP-1 Intake
*
prev
next
( X )
GLP-1 Medical Qualification Deposit
This non-refundable deposit covers your consultation, initial intake, and good faith exam prep. You must complete this payment to book your visit.
$
39.99
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Submit
Should be Empty: