Select all the programs that match your goals.
Weight Management: Medical weight loss programs tailored for you.
Longevity & Cellular Health: Optimize aging, support cellular repair and longevity.
Energy & Muscle Health: Boost energy, strength, and daily performance.
Metabolic Health: Improve blood sugar, cholesterol, and overall metabolic markers.
Peptide Therapy: Advanced peptide programs for targeted results.
First Name
*
Last Name
*
Email
*
Date of birth
*
Sex Assigned at Birth
*
Female
Male
Height
*
cm
in
Current Weight
*
lbs
kg
Goal Weight
*
lbs
kg
Occupation
City
State
Phone
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
What Are Your Primary Health Goals?
Lose weight
Reduce body fat
Build lean muscle
Increase energy
Improve focus and concentration
Reduce brain fog
Improve athletic performance
Improve recovery after exercise
Improve sleep
Reduce stress
Improve sexual wellness
Increase libido
Hormone optimization
Healthy aging
Longevity
Improve overall health
Other
Which Best Describes You?
I want to lose less than 20 pounds
I want to lose 20–50 pounds
I want to lose more than 50 pounds
My main concern is energy
My main concern is hormones
My main concern is brain performance
My main concern is healthy aging
I want a complete health optimization program
Metabolic Health Assessment
Have you experienced any of the following?
Difficulty losing weight despite diet and exercise
Weight gain over the past several years
Strong cravings for sweets or carbohydrates
Feeling hungry shortly after eating
Eating large portions before feeling full
Late-night snacking
Emotional eating
Frequent sugar cravings
Belly fat that is difficult to lose
Medical Conditions
Have you ever been diagnosed with any of the following?
Prediabetes
Type 2 Diabetes
High Blood Pressure
High Cholesterol
Fatty Liver Disease
Sleep Apnea
Polycystic Ovary Syndrome (PCOS)
Metabolic Syndrome
Heart Disease
Stroke
Kidney Disease
Liver Disease
None of the Above
Current Weight Loss Treatments
Are you currently taking or have you previously taken any of the following?
Semaglutide
Tirzepatide
Other GLP-1 medication
Phentermine
Contrave
Qsymia
Metformin
None
If yes, please describe your experience:
Lifestyle Assessment
How many days per week do you exercise?
0
1–2
3–4
5+
How many hours do you sleep each night?
Less than 5
5–6
6–7
7–8
More than 8
How would you rate your stress level?
Low
Moderate
High
Very High
Upload Your Lab Results
Recent bloodwork from the past 12 months (optional)
Upload Medical Records File
Medication list, diagnoses, or prior treatment notes (optional)
