Weight Loss Consultation Intake Form

Weight Loss Consultation Intake Form
Full Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*
Phone Number
Please enter a valid phone number.
What is motivating you to begin your weight loss journey?*
Have you previously attempted to lose weight using any of the methods listed below?*

PhentermineSemaglutideTirzepatideContraveQysmiaWeight WatchersIntermittent FastingBariatric SurgeryNone of the AboveOther
Please check any medical conditions you currently have or have had in the past:*

High Blood PressureDiabetes or PrediabetesHeart DiseaseThyroid ProblemsPCOS (Polycystic Ovary Syndrome)EndometriosisSleep ApneaDepression or AnxietyNoneOther
Please list any medications or supplements you are currently taking (include dosage):*
Do you currently exercise?*

YesNo
Do you Smoke?*

YesNoOther
Do you consume alcohol?*

YesNoOther
If Yes to Exercise--- describe type and Frequency*
If Yes to Alcohol, How much, how often*
Current Height and Weight*
What was your lowest weight?*
What is your Goal weight?*
What has been your biggest challenge in losing weight?*
Do you experience any of the following?*

DepressionAnxietyPanic attacksSleep disturbances (ex: Insomnia or excessive sleepinessSuicidal thoughts or ideationNone of the Above
Additional notes:
Signature*
Date*

MonthDayYear
Date
My Products
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Consultation
Please Note: A $75 consultation fee (standard copay for your initial visit) is required to schedule your first appointment. Routine follow-up visits are recommended every 3 months to monitor progress and adjust treatment as needed. Each routine 3-month follow-up visit carries a $75 fee. If a visit is scheduled for an issue unrelated to weight management, a separate visit fee will apply.(You will be redirected to PayPal to complete your payment.)

$75.00 Quantity

Total

$0.00
Payment Methods

Fastlane Checkout

Choose from one of the PayPal options to make your payment.

Contact Info

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