Access to weight loss injections with initial doctor consultation 100% online!

GLP-1 treatment now available in Illinois!

Active patients in Illinois
  • NO insurance, NO waitlist, and NO hidden fees.
  • INJECTABLE GLP-1 plans available.
  • Get 15 Minute Weight Loss Consultation with Physician
    (Unique to your Weight Loss Journey with Outstanding Results)

Compounded Semaglutide and Tirzepatide

Doctor-guided care, designed around your lifestyle.
Your partner in health — from consultation to results.
Most affordable GLP-1 treatment.

AM URGENT CARE

Medical Weight Loss Intake Form

Personal Information

Please enter a valid U.S. phone number (10 or 11 digits).
Please enter a valid ZIP code (12345 or 12345-6789, up to 4 digits after the hyphen).
Please enter a valid U.S. phone number (10 or 11 digits).

Personal History

Personal History Questionnaires

Medical Conditions

Please select Yes or No for each condition below.

Additional Questions

Have you had prior bariatric (weight loss) surgery or any abdominal/pelvic surgeries?

Blood Pressure

What is your current or average blood pressure range?

Program Benefits

Please select Yes or No for each benefit below.

Diet and Lifestyle

Weight Loss Goals

What is your current height & weight?

Your BMI
0.0

Medical History Details

SYMPTOM NO, NEVER YES, CURRENTLY NO, BUT WITHIN THE LAST YEAR NO, MORE THAN ONE YEAR AGO

Patient Signature

Please sign below to acknowledge that all the information provided is accurate and complete to the best of your knowledge.

Legal Disclaimers:

Compounded semaglutide is not approved by the FDA. The FDA does not evaluate compounded products for safety, effectiveness, or quality.

Zepbound and Mounjaro are registered trademarks of Eli Lilly and Company. Ozempic, Wegovy, Saxenda, and Victoza are registered trademarks of Novo Nordisk A/S. Byetta and Bydureon are registered trademarks of Amylin Pharmaceuticals, Inc.

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