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Basic Information
First Name
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Last Name
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DOB
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Phone Number
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Email
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State
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Are you 18 years of age or older?
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No
You must be 18 years of age or older to continue.
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Goals
What are your primary goals?
Please select at least one primary goal.
Weight Loss
Appetite Control
Improve Energy
Recovery & Performance
Metabolic Health
Longevity & Wellness
Please Write your outcome.
Which outcome is MOST important to you right now?
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Body Information
Height
feet
inches
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Pounds
lbs
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Have you recently lost or gained a significant amount of weight?
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No
Please describe your recent weight change.
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Medical History
Have you ever been diagnosed with any of the following?
Please select at least one option.
Type 1 Diabetes
Type 2 Diabetes
High Blood Pressure
Heart Disease
Thyroid Disorder
Cancer
Pancreatitis
Kidney Disease
Liver Disease
Eating Disorder
None
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Medications
Are you currently taking any prescription medications?
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No
Please select an option.
Please list your current medications
Please list your medications.
Are you currently using any GLP-1 medications or peptides?
Yes
No
Please select an option.
Please list them
Please list GLP-1 medications or peptides.
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Safety Screening
Do you have any known medication allergies?
Yes
No
Please select an option.
Please list your allergies
Please list your allergies.
Have you ever experienced severe side effects from injectable medications?
Yes
No
Please select an option.
Have you previously stopped a peptide or GLP-1 medication due to side effects?
Yes
No
Please select an option.
Please explain
Please explain.
Are you currently pregnant, breastfeeding, or trying to become pregnant?
Yes
No
Please select an option.
Have you ever been diagnosed with pancreatitis or medullary thyroid cancer?
Yes
No
Please select an option.
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Metabolic Coaching
Are you interested in receiving metabolic coaching and accountability support?
Yes
No
Please select an option.
Are you willing to follow a structured wellness protocol that may include nutrition, movement, and lifestyle recommendations?
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No
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Consent
I understand my information will be reviewed by a licensed provider and submission does not guarantee approval for treatment.
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