24Sculpt.com membership

Where are you presently located?* This field is required.We need to make sure we are currently licensed in your state.

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Email Verified

The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification

••••

Address* This field is required.Please enter your street address, city, state and zip code. The address entered here will be the address used to ship your medication to.

Street Address

Street Address Line 2

City

State

Zip Code

Country

Phone Number* This field is required.

Please enter a valid phone number.

Date of Birth* This field is required.Please fill in the date that you were born.

Date

Do you or anyone in your family have a history of medullary thyroid carcinoma?* This field is required.

YESNO

Do you have a history of pancreatitis?* This field is required.

YESNO

What is your weight and height?* This field is required.

Are you an existing 24sculpt.com patient?* This field is required.

YESNO

Thank you for continuing to use 24Sculpt for your medical weight loss needs. Although you are a returning patient, we have a few questions to ask to make sure that nothing has changed since your last visit.

Are you currently taking semaglutide/cyanocobalamin or tirzepatide/niacinamide?

semaglutide/cyanocobalamin

tirzepatide/niacinamide

When was the last time you took semaglutide/B12?* This field is required.

Less than 1 month ago

More than 1 month ago

When was the last time you took tirzepatide/niacinamide?* This field is required.

Less than 1 month ago

More than 1 month ago

Would you like to increase the dose of your medication today?* This field is required.

YESNO

Would you like to increase the dose of your medication today?* This field is required.

YESNO

Select your goal of weight loss treatment* This field is required.

Improve quality of life

Treat and reverse the complications of obesity

Prevent the complications of obesity

Weight Reduction & Safety Disclosure* This field is required.All fields are required to be checked.

I have read the Weight Reduction & Safety Disclosure and Consent to Proceed* This field is required.

AGREE

How would you categorize your current weight?* This field is required.

Underweight (BMI below 18.5)

Healthy weight (BMI between 18.5 and 24.9)

BMI between 27 and 29.9

Obese (BMI between 30 and 39.9)

Morbidly obese (BMI above 40)

Unsure

What is your waist size/circumference in inches?* This field is required.Type a number in inches

Inches

Which of these conditions do you currently have or have had in the past?* This field is required.

None of the conditions below

Liver Disease or Kidney Disease

Diabetic Retinopathy

Depression or other mental health disorder

Gastroparesis

Pancreatitis

Gallbladder Disease

Hypoglycemia (low glucose)

Arrhythmias or Abnormal Heart Rate

Seizure Disorder (epilepsy)

Suicidal Behavior and Ideation

Thyroid Tumors or Cancer

Multiple Endocrine Neoplasia Syndrome

Which of these weight loss measures have you tried?* This field is required.

Weight loss exercises

Diet

Portion control and calorie count

Behavior therapy by a trained personnel

Weight loss supplements

Weight loss Apps

Are you currently on or have you previously used semaglutide, ozempic, or wegovy?* This field is required.

I am currently on semaglutide, ozempic, or wegovy.

I have used semaglutide, ozempic, or wegovy within the past month.

It has been more than 1 month since I have used semaglutide, ozempic, or wegovy.

I have never used semaglutide, ozempic, or wegovy.

Are you currently on or have you previously used tirzepatide, mounjaro, or zepbound?* This field is required.

I am currently on tirzepatide, mounjaro, or zepbound.

I have used tirzepatide, mounjaro, or zepbound within the past month.

It has been more than 1 month since I have used tirzepatide, mounjaro, or zepbound.

I have never used tirzepatide, mounjaro, or zepbound.

Which of these weight loss interventions have you explored in the past?* This field is required.

Prescription medication for weight loss

Liposuction

Bariatric surgery

Acupuncture

Other surgical interventions

Other interventions

None of the above medical interventions

Please upload a full body (head to toe) image of yourself. (Optional)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Are you allergic to any drug?* This field is required.

YESNo drug allergies (NKDA)

What medications are you allergic to?* This field is required.

Select the underlying medical conditions you have currently or have had in the past.* This field is required.

None, I do NOT have any chronic medical or psychiatric conditions

Heart disease

Hypertension

Liver disease

Kidney disease

Diabetes

High cholesterol

Thyroid disorder

Psychiatric condition

HIV/AIDS

Other condition

Type of heart disease* This field is required.

Coronary Artery Disease (CAD) or heart attack

Heart Valve Disease

Arrhythmias or abnormal heartbeat

Heart Failure or CHF

Congenital Heart Disease

Cardiomyopathy (Heart Muscle Disease)

Pericardial Disease

Other heart diseases

How stable or controlled is your diabetes?* This field is required.

Well controlled (Glucose below 150 or HbA1c less than 8)

Somewhat controlled (Glucose below 200 or HbA1c less than 9)

Uncontrolled Diabetes (Glucose over 200 or HbA1c over 9)

Select applicable psychiatric conditions* This field is required.

Depression

Anxiety

Panic Disorder

Bipolar or mood disorder

Schizophrenia or psychosis

PTSD

Eating disorder

OCD

Other psychiatric conditions

What's your average blood pressure reading?* This field is required.

Normal (Less than 140/90)

Elevated (Less than 160/100)

Uncontrolled (Over 160/100)

Are you currently taking any medication?* This field is required.

YESNO

Enter medication names* This field is required.

What is your biological sex (gender at birth)?* This field is required.

FemaleMale

Are you currently breastfeeding (nursing)?* This field is required.

YESNO

When did your last menstrual cycle end (Pregnancy Screening)?* This field is required.

My period ended within the last 30 days

I AM PREGNANT

I am currently on my period

I haven't had a period in 30 days (Late period)

I am a transgender woman

I am postmenopausal and do not have menstrual cycles

I am a child and have NEVER had a menstrual cycle (Premenarchal)

Please select a reason for your late, missed, or irregular cycle. (Rule Out Pregnancy.)* This field is required.

I am on birth control or hormone therapy

Due to a medical condition that causes menstrual irregularity

After a surgical procedure such as hysterectomy or endometrial ablation

I may be pregnant

Other reasons

Please explain why your cycle is irregular or missed.* This field is required.

Select applicable surgical history.* This field is required.

None, No surgical past

Appendectomy

Breast augmentation

C-section

Gallbladder surgery

Hysterectomy

Hernia repair

Mastectomy

Orthopedic surgery

Tonsillectomy

Other surgery

List any other past surgeries.* This field is required.

Which of these social histories applies to you?* This field is required.

I drink coffee or caffeinated drinks regularly

Current smoker (Vape, cigarette or tobacco)

Former cigarette or tobacco use

Marijuana use

Opioid Addiction

Alcohol Addiction

Recreational or illicit drug use

None of the above

Payment and Refund Policy - by clicking each boxy below you agree to this policy* This field is required.All fields are required to be checked.

Informed Consent and Authorization to Administer Treatment* This field is required.

Semaglutide/Tirzepatide Consent Form* This field is required.

Were you referred by someone? If so, please type their full name (first and last) below.

24Sculpt.com membership