First Name *

Last Name *

Phone *

Email *

Date of birth *

Street Address *

City

State

Postal code

Sex assigned at birth. *

Female

Male

Prefer not to answer

Height (inches) *

Initial weight (lbs) *

Initial BMI (Calculated) *

Desired weight? *

How long have you struggled with your weight or had interest in losing weight? *

What weight loss drugs/programs/diets have your tried? *

Which services are you interested in? *

Wellness consulting (diet, supplements, sleep, exercise, etc..)

Plastic Surgery

Botox / Filler

Something else?

Please share

Health History

Please list any chronic health problems you may have. *

Do you currently have or have you ever been diagnosed with pre-diabetes? *

Yes

Do you have Type 1 Diabetes? *

Yes

Do you have Type 2 Diabetes? *

Yes

Do you have or have you had any gastrointestinal (Stomach/Intestinal) conditions? *

Yes

If yes, what gastointestinal condition do you have?

Do you have or have you had: Multiple Endocrine Neoplasia Syndrome Type 2 or Medullary thyroid cancer? *

Yes

Do you or have you ever had Pancreatitis? *

Yes

Currently pregnant or breast feeding? *

Yes

Have you ever been diagnosed with an eating disorder? *

Yes

Allergy *

List any medications you are taking (Prescription and over-the-counter) *

What best describes your smoking habits? *

None

0-1 package per day

1-2 package per day

2+ packages per day

Average number of alcoholic drinks each week? *

Do you often feel tired, fatigued, or notice a decrease in energy levels, even after adequate sleep? *

Yes

Sometimes

Do you have a medication preference? *

Semaglutide

Tirzepatide

I'm not sure

Is there anything else you would like us to know?

Sign here *

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