We have implemented a streamlined Momentum Informed Consent process. By checking this box, I agree to receive text messages from Momentum Health regarding my appointments, prescriptions, or relevant health updates. Message & data rates may apply. Consent is not a condition of purchase.

What is your motivation level?

Just Exploring

Moderately Motivated

Highly Motivated 😊

Reason you want to lose weight?

Overall Health 💪🏼

Special Event 🎉

Upcoming Vacation 😎

Look & Feel Better 😊

*Select all that apply*

Let's calculate your BMI

Feet (Height)

Inches

Weight lbs.

BMI (Body Mass Index)

State

BMI Consent

The traditional use of weight loss medications is for individuals with a BMI of 30 and above or to those who are overweight who have associated health conditions. Using it for someone with a BMI range (27-29) without an accompanying health condition is termed "off-label." Using a medication "off-label" refers to the practice of prescribing a drug for a purpose, age group, dosage, or form of administration that is not included in the approved labeling by regulatory agencies like the U.S. Food and Drug Administration (FDA). While a medication undergoes rigorous testing for specific uses before receiving approval, healthcare providers may discover through clinical experience or research that it can be effective for treating other conditions. There may be benefits such as weight reduction for individuals within your range. If you agree to this off-label use, it's crucial to follow the prescribed regimen and report any concerns. Please discuss any questions with us.

I acknowledge that I have read and understood the above information.

I have read the above information, and I do not wish to continue.

What is your gender at birth?

Male

Female

Are you currently, or have you in the past two months, taken any of the following medications?

Semaglutide (Ozempic, Wegovy, Rybelsus)

Tirzepatide (Zepbound, Mounjaro)

None of these

Truthfulness Consent

Please attest to the following confirming that all information you have provided to us is true and complete.

Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

I have read the above information and I do consent and wish to move forward

I have read the above information and I do not wish to continue