Weight Loss Interest & Eligibility Assessment

First Name

First NameLast Name

Gender

Date of Birth

Date

Height

Weight

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Do you suffer from any of these common health issues?

Are you currently taking any medications for weight loss?

Which medication(s)?

Have you decided which treatment is right for you?

Please note:

As part of our medical weight management program, we currently offer prescriptions for Wegovy® (injectable and oral tablet forms) and Zepbound® (injectable form). An oral form of Zepbound® is expected to be available soon. Foundayo® is also available in an oral tablet form.

At this time, we ask that you contact your insurance provider to verify coverage for any prescribed medications, as benefits and coverage requirements vary by plan.

A representative from our clinic will contact you soon to discuss your options and answer any questions you may have. We look forward to assisting you on your weight management journey.

Which payment option describes you best?

Please provide your insurance information so that we may verify your policy's benefits.

How would you like to enter your insurance information?

Front of Insurance Card

Back of Insurance Card

Insurance Company

For example, Blue Cross/Blue Shield, United Healthcare, Medicare

Primary Insured

Insurance Group No.

Insurance Policy No.