Clone of Weight Loss Program Intake Form

Weight Loss Program Intake Form
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Preferred Method of Communication: *
How did you hear about this program?
Next Steps
What weight loss medication are you interested in?

Semaglutide Daily Oral Disintegrating TabletSemaglutide Weekly InjectionTrizepatide Daily Oral Disintegrating TabletTrizepatide Weekly InjectionI'm not sure yet
Are you also interested in adding peptide or wellness therapy? (Check all that apply)

NAD+ InjectionsGlutathione InjectionsLipo-Mino-Mix "Skinny Shot"Not at this timeI’d like more information
- You’ll receive an alert titled “Please Complete Intake Review for Weight Loss.”This is not an appointment—it simply allows us to send your intake and consent forms.
- Check your email to complete the forms. Once submitted, our Medical Director will review your information and we’ll follow up with next steps.
  Please note: To qualify, your BMI must be greater than 23.
- To complete your guest profile, download the Urban You app and add a payment method. Your card will not be charged.
- Download the Urban You app:
  - App Store: https://tr.ee/UYApple
  - Google Play: https://tr.ee/UYGoogle
Need help? Give our office a call—we’re happy to assist!
Intake & Processing Fee

A $35 non-refundable processing fee is required to begin your intake. This fee covers a comprehensive review of your information by a Registered Nurse, who will then collaborate with our Medical Director to determine your eligibility for treatment. Once your intake has been submitted, a member of our licensed staff will reach out to collect the $35 processing fee and guide you through the next steps
Should be Empty:

Weight Loss Program Intake Form

Next Steps

Intake & Processing Fee