First Name
*
Last Name
*
Email
*
Phone
*
I agree to be contacted by phone, text, and email with a quick quote.
Q1. What is your primary goal(s) right now?
Lose 15 pounds or less
Lose 15-40 pounds
Lose 40-60 pounds
Lose 60-80 pounds
Lose 80+ pounds
Improve Energy
Other
Q2. How soon do you want to start?
*
Right away
2–4 weeks
I am gathering info
Q3. Have you used weightloss medication before?
*
Yes, currently on it
Yes, in the past
No, first time
Q4. A clinician will review your history. Do any of these apply? (Check all that apply)
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Pregnant or breastfeeding
History of pancreatitis
Type 1 diabetes
Personal or family history of medullary thyroid carcinoma or MEN2
None of these
Q5. Which support style fits you best?
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Weekly check-ins
Bi-weekly check-ins
I prefer app-based support
Q6. Are you in the Clemson area?
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Yes, I am local
I can travel to the clinic
I prefer telehealth
