Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
*
-
Month
-
Day
Year
Date
What is your current weight loss or lifestyle goal?
*
What have you tried for weight loss in the past?
*
Have you been on a GLP-1 agonist in the past?
*
Yes
No
If so, list here
List all medical conditions here
*
Please list any medications you are taking below
*
On average, how many hours of sleep do you get each night?
*
Do you follow a specific diet plan?
*
Yes
No
If yes, list here
How often do you exercise?
*
Every day
Five times a week
Three times a week
Occasionally
Never
What form of exercise do you participate in?
*
Are you a smoker ?
*
Yes
No
Do you drink alcohol?
*
Yes
No
If so, how often (drinks/week)
Have you watched our video on how to properly use your medication?
*
Yes
No
Are you confident that you are using the medication properly?
*
Yes
No
Do you have any issues with using the medication. If yes, please explain below:
*
Yes
No
Please explain
*
Other concerns
*
Please verify that you are human
*
Submit
Should be Empty: