First Name *

Last Name *

Phone *

Email *

What are your primary fitness goals?

Lose Weight

Build Muscle

Improve Cardiovascular Health

Maintenance

Do you have any specific fitness challenges or limitations we should be aware of?

How did you hear about our company?

Have you, or has any parent, sibling, or child of yours, ever been diagnosed with medullary thyroid cancer or MEN 2 (Multiple Endocrine Neoplasia Type 2)? *

Have you ever had a serious allergic reaction to Ozempic, Wegovy, Mounjaro, Zepbound, Saxenda, Trulicity, Victoza, or Rybelsus? *

Are you currently pregnant, breastfeeding, or actively trying to become pregnant? *

Do you have a surgery or procedure scheduled in the next two weeks that requires general anesthesia? *

Are you currently taking insulin or a sulfonylurea (glipizide, glimepiride, glyburide)? *

In the past 12 months, have you experienced thoughts of self-harm or suicide? *

Have you taken a GLP-1 medication before? *

Basic Information *

Height
Weight in pounds (lb)
Sex at birth
Age

Have you ever been diagnosed with, hospitalized for, or told you had any of the following? (Check all that apply) *

Pancreatitis (inflammation of the pancreas)

Gastroparesis (delayed stomach emptying)

Type 1 diabetes

Severe kidney disease or dialysis

Severe liver disease or cirrhosis

Diabetic eye disease (retinopathy)

Bariatric (weight loss) surgery in the past 6 months

An eating disorder such as anorexia, bulimia, or binge eating disorder

None of these

How much weight are you hoping to lose? *

My Commitment to Show Up to the Consultation Meeting (Fully Deductible) *

$ 49

By checking this box, I consent to receive non-marketing text messages from AthleticsMD® and its subsidiary Prehabilitation Centers of America about appointment reminders, intake and clinical form completion, care coordination between visits, and clinical follow-up related to my treatment. Message frequency varies. Message and data rates may apply. Text HELP for assistance. Reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional text messages from AthleticsMD® (also doing business as Prehabilitation Centers of America) at the phone number provided, including program announcements, wellness content, special offers, event invitations, and referral incentives. Frequency may vary. Message and data rates may apply. Text HELP for assistance. Reply STOP to opt out.