Medical Weight Loss Assessment
Complete your self-pay assessment, confirm acknowledgements, and review medical details to submit for eligibility review.
Patient Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Mobile Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Program Acknowledgements
I understand this is a self-pay program, payment is my responsibility, charges may apply separately for labs, medications, supplements, and follow-up visits, treatment is not guaranteed, and participation in lifestyle changes is required.
*
Acknowledged
Physical Measurements
Height (inches)
*
Weight (lb)
*
Goal Weight (optional)
Weight Loss Goals
What is your main goal for weight loss?
*
Improve health
Increase energy
Improve mobility
Fit into clothing better
Prepare for a special event
Lower weight-related risk factors
Other
Current Medications and Allergies
Current medications, including names and doses
*
Allergies and reaction details
*
GLP-1 History
Have you ever used a GLP-1 medication before?
*
Yes
No
Contraindication Screening
Final Certification and Signature
When would you like to start?
*
As soon as possible
Within the next 1-2 weeks
Within the next month
Just exploring options
Agreement
*
I certify that the information provided is accurate and complete
I understand this is a self-pay program and payment is my responsibility
I understand treatment is not guaranteed and eligibility is determined by the provider
I agree to the above terms
Electronic Signature
*
Date
*
-
Month
-
Day
Year
Date
GLP-1 medication name
If applicable
Highest or most recent dose
If applicable
Approximate length of use
If applicable
Results and side effects
If applicable
Reason for stopping
If applicable
Has a doctor ever told you that you or a family member had medullary thyroid cancer (MTC) or MEN2?
*
Yes
No
Unsure
Have you ever had pancreatitis, gallbladder disease, or severe gastroparesis?
*
Yes
No
Unsure
Have you ever had a serious allergic reaction to semaglutide, tirzepatide, or another GLP-1 medication?
*
Yes
No
Unsure
Are you pregnant, breastfeeding, trying to become pregnant, or planning pregnancy?
*
Yes
No
Not Applicable
Submit Assessment
Submit Assessment
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