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Wellness Consultation

Ready to take the next step toward a healthier, more confident you? Our personalized weight loss programs — including advanced GLP-1 options like tirzepatide and semaglutide — are designed to support sustainable results and whole-body wellness. Fill out our weight loss consultation form today to see if you qualify and let our medical team create a customized plan tailored to your goals. Your transformation starts with one simple step.

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Multi-line address
Birthday
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Please indicate the reasons you think are contributing to having excess weight.
What methods and/or interventions have you tried in the past?
Do you experience episodes of binge eating?
Yes
No
Do you skip meals?
Yes
No
Do you stress eat?
Yes
No
Are you currently at your heaviest weight?
Yes
No
Do you have known allergies/sensitivities to:
Have you ever fainted during injections or blood draw?
No
Yes
Have you ever had an adverse reaction or significant side effect to any weight loss medication or treatment?
No
Yes
Do you take medication for diabetes?
No
Yes
Do you take any medication that may cause increased risk of bleeding or delayed healing such as anti-platelets, blood thinners, corticosteroids, or nsaids?
No
Yes

Female Medical History

Are you currently:
Birth Control Method:

Male Medical History

Have you had a vasectomy?
No
Yes

General Medical History

Have you or a family member ever been diagnosed with thyroid cancer or multiple endocrine neoplasia syndrome type 2?
No
Yes
Have you ever been diagnosed or currently have:
Do you have any other medical issues not listed above?
No
Yes

Please list all medications, over the counter drugs, and herbal supplements you are currently taking. Please include any prescription topical creams and hormone replacement therapy medications/implants.

Acknowledgement: I affirm the information I have provided regarding my health history, medication record, and prior surgeries and aesthetic treatments is accurate to the best of my knowledge. I acknowledge that the practitioner is not responsible for any errors that may occur as a result of any omissions or incorrect information on this form.

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