Weight Loss & Fertility Optimization

Weight Loss & Fertility Optimization

INTAKE FORM
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever been diagnosed with any of the following?*

PCOSThyroid DisorderDiabetesPre-DiabeticNone of the Above
Are you currently trying to conceive?*

YesNo
Are you currently taking any medications?*

YesNo
If you are taking any medications or vitamins, please list them here.
Have you ever used any weight loss medications such as GLP-1s like Semaglutide or Tirzepatide?*

NoUnsureYes
If yes, which one?
Age*
Height (INCHES not feet)*
Weight (lb)*
BMI
BMI Result
What are your main goals for joining our weight-loss program?*

General healthImprove my fertilityPrepare for surgeryOther
Do you have regular menstrual cycles?*

YesNot ApplicableNo
What is your preferred program start date?*

MonthDayYear
Are you currently under the care of a fertility specialist?*

YesNo
How many prior pregnancies have you had? If none, input 0.*
How did you hear about NCCRM Weigh Loss Program?*

GoogleFacebookInstagaramYoutubeTikTokPinterestTwitter (x)SpotifyRadioEventDoctor ReferralFamily ReferralFriend ReferralOther
CONSENT: By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and consent to be contacted by NCCRM regarding program enrollment and follow-up care.*

I agree and consent
Signature*

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