Qualify for Semaglutide
Please Complete this pre-screening form to help us qualify you to take Semaglutide for weight loss.
Email *
First Name *
Last Name *
Biological Sex *
Address *
Phone number *
Date of Birth *
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Current weight in pounds *
Current Height in Feet & Inches *
Have you ever taken prescription diet supplements before? *
Are you comfortable giving yourself an injection? *
Please list any drug allergies that you may have: (If None, type None) *
Please list any Food allergies that you may have: (If None, type None) *
Do you have medical insurance? *
If yes, What is the name of your medical insurance company?
Are you diabetic? *
Do you have high blood pressure? *
List any current or previous medical conditions that you have: (If None, type None) *
List any current medications or supplements that you are taking: (If None, type None) *
To your knowledge, Have you ever been told that you have Pre-Diabetes, or Diabetes? *
Do you have any history of thyroid disease or cancer? *
Any history of thyroid disease or cancers in your family? *
To your knowledge, Do you have Gallbladder disease? *
To your knowledge, have you ever been diagnosed with Pancreatitis? *
To your knowledge, Have you ever been diagnosed with Retinopathy? *
Do you have any of the following symptoms on a regular basis? (select all that apply)
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