Free screening for our Semaglutide Weight Management Program (and if you are a candidate for insurance coverage)
"
*
" indicates required fields
Step
1
of
11
9%
Name
*
Phone
*
Email
*
1. Have you tried and failed other weight loss programs in the past?
*
Yes
No
2. Do you struggle with carbohydrate cravings?
*
Yes
No
3. Do you feel hungry most of the time?
*
Yes
No
4. Do you have a history of type 2 diabetes?
*
Yes
No
5. Do you have a history of high cholesterol?
*
Yes
No
6. Do you gain weight around your abdomen?
*
Yes
No
Hidden
Score
7. Do you have a history of kidney problems?
*
Yes
No
8. Do you have a history of pancreatitis?
*
Yes
No
9. Do you have a history of suicide or suicidal thoughts?
*
Yes
No
10. Do you have a personal or family history of thyroid cancer?
*
Yes
No
Hidden
non-candidate-Score
Hidden
non-candidate
Hidden
non-candidate: Kidney problems
Hidden
non-candidate: Pancreatitis Hx
Hidden
non-candidate: Mental health
Hidden
non-candidate: Thyroid Cancer
Hidden
3-5
Hidden
6-10
Hidden
11-14
Email
This field is for validation purposes and should be left unchanged.
