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Weight Loss Journey

Step1: Medical Compatibility Form & Waiver

Please re-confirm your response to:

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Birth Day *

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Height

Weight (lbs)

BMI

Are you pregnant or are you trying to become pregnant?
Do you really have or have had
Do you still have cancer?
Have you ever been diagnosed with Anorexia?
Are you currently taking diuretics?
Do you have history of allergy to semaglutide or other glp-1?

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Semaglutide & Tirzepatide

a.k.a Ozempic & Mounjaro (GLP -1 Agonist)

Compatibility Form & Waiver

*We need at least your email address to continue...

Are you sure your birthday is January 3, 2023? Please confirm your birthday below:

Please enter your phone number one number at a time starting from the area code. For example: 321 456 7891, don't worry about adding spaces. No need to add the country code (+1) either.

Gender
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Birth Day *

*Age was populated using your Birthday.

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*Please provide your complete shipping address or at least select from one of the autocomplete suggestions.

Height

Weight (lbs)

BMI

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Weight History

When did you become overweight?
Did you ever gain more than 20 pounds in less than 3 months?

How much did you weigh...

Triggers for your weight gain (check all that apply):
Previous weight-loss programs (check all that apply):
Have you ever taken any of these medications? (check all that apply):
Did it work?

Medical History

Do you exercise?
Are you pregnant or are you trying to become pregnant?

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Do you feel rested in the morning?
Please check if you are or have had any of the following (check all that apply):

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Have you ever been diagnosed with an eating disorder?
Do you still have cancer?

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Is it anorexia?

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Are you currently taking diuretics?

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Past surgical history (check all that apply):
Are you currently taking any medication?
Do you have history of allergy to semaglutide or other glp-1?

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Do you have allergies?
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Patient Waiver Acknowledgement and Signature

Patient Signature

Patient Full Name

Complete all necessary fields before you can submit.

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Compatibility Form & Waiver Help

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