Medical Weight Loss Consultation
Share your goals and preferences so our licensed provider can review eligibility separately.
Contact Information
First Name
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Last Name
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Date of Birth
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Day
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Month
Year
Date
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
Your Goals
What are your primary goals?
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Weight loss
Improve overall health
Improve energy
Blood sugar support
Increase confidence
Other
Current Weight
Goal Weight
Medical Weight Loss History
Have you ever used a GLP-1 medication before?
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No, this is my first time.
Yes, I'm currently taking a GLP-1 medication.
Yes, I've used a GLP-1 medication in the past.
Which GLP-1 medication are you currently taking?
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Semaglutide (Ozempic®, Wegovy®, or compounded semaglutide)
Tirzepatide (Mounjaro®, Zepbound®, or compounded tirzepatide)
I'm not sure
Other
Please tell us the name of your medication, if known.
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What is your current weekly dose?
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What would you like to do?
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Continue my current medication.
Increase my dose.
Switch medications.
Restart after a break.
I'm not sure.
Have you experienced any side effects?
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No
Yes
Please describe your side effects.
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Which medication(s) have you previously used?
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Approximately when did you stop taking it?
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Why did you stop?
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Reached my goal
Cost
Side effects
Medication shortage
Didn't achieve the results I hoped for
Other
Did you experience any side effects while taking a GLP-1 medication?
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No
Yes
Please describe your side effects.
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Allergies
Do you have any known allergies or sensitivities to medications or compounded ingredients?
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No
Yes
Please describe your allergy or sensitivity.Examples: Vitamin B12, glycine, preservatives, adhesives, latex, or any previous reaction to injectable medications.
*
Consent and Signature
Agreement
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I certify that the information I have provided is accurate.
I understand this form does not guarantee approval for treatment.
I understand all prescriptions are determined by a licensed medical provider.
I consent to being contacted regarding my inquiry.
Electronic Signature
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Date
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Month
-
Day
Year
Date
Acknowledgment of Medical Review
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I understand my consultation request may be reviewed by a licensed medical provider.
I understand treatment decisions are made only after provider evaluation.
Communication Consent
I agree to be contacted by email or phone regarding my inquiry.
I understand messages may include scheduling or follow-up information.
Additional Comments
Next Steps
How would you like to begin?
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I'd like a consultation first. — I'd like to discuss my goals, ask questions, and receive personalized guidance before beginning treatment.
I'm ready to begin my provider evaluation. — I'm ready to complete my medical evaluation through our licensed provider to determine if treatment is appropriate.
Begin My Journey!
Begin My Journey!
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