Your Personalized Weight Loss Plan Begins Here What is your email? What are your weight loss goals? Lose 1-20lbs for goodLose 21-50lbs for goodLose over 50 for goodMaintain my healthy weightNone of the above What weight loss initiatives have you tried in the past? Select all that apply. Exercise Dieting Weight Loss Supplements Intermittent Fasting None of the above What is your height? Feet: 4567 Inches: 01234567891011 What is your current weight? (lbs) Which GLP-1 are you interested in? Compounded Semaglutide InjectionsCompounded Tirzepatide InjectionsOral SemaglutideOral Tirzepatide Which state should we ship your medication to? AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWisconsinWyoming Have you ever taken or are you currently taking a GLP-1 medication? NoYes Which GLP-1 medication are you currently taking? Compounded Semaglutide InjectionsCompounded Tirzepatide InjectionsBranded Semaglutide (Wegovy or Ozempic)Branded Tirzepatide (Zepbound or Mounjaro)Oral SemaglutideOral Tirzepatide What is the approximate date of your last dose? What is the strength of your last dose? Please provide the strength in milligrams (mg) if known. Please upload a copy of your current prescription. If you do not have a digital copy, it is acceptable to upload an image of your medication label. If you qualify, would you like to purchase a 3 or 6 month bundle? NoYes Which bundle would you prefer? Pricing is based on your dosage, please check medication-specific page for exact expected cost. 3-Month Compounded Semaglutide Bundle $650-$7506-Month Compounded Semaglutide Bundle $1,200-$1,4003-month Compounded Tirzepatide Bundle $900-$1,5006-month Compounded Tirzepatide Bundle $1,700-$2,900 Are you currently pregnant, breastfeeding, or planning to become pregnant within the next two months? NoYes Do you currently have any of the following medical conditions? None of these Gastroparesis Pancreatic Cancer Pancreatitis Type 1 Diabetes or diabetes requiring insulin Hypoglycemia Medullary Thyroid Cancer (MTC) or family history of MTC Bipolar Disorder Schizophrenia Family or personal history of Multiple Endocrine Neoplasia (MEN-2) syndrome Anorexia or Bulimia Current symptomatic gallstones or active gallbladder disease Active Substance Abuse Disorder Please check all current and past medical conditions. None of these Hypertension (high blood pressure) High Cholesterol Type 2 Diabetes Obstructive Sleep Apnea Gout Metabolic Syndrome Heart Disease, Stroke, or Peripheral Vascular Disease Heart Failure Atrial Fibrillation or Flutter Tachycardia or Fast Heart Rate Any ECG Abnormality or Heart Rhythm Abnormality Are you currently taking any medications including prescription, over-the-counter, and supplements? NoYes Please list all medications you are currently taking: Please list all of your known allergies. Please type N/A if none. Weight gain can cause unique effects on patients. Do you experience any of the following? Low Libido Hair Loss Skin Issues Cognition Issues None of these Would you like to add anti-nausea medication to your medical weight loss order? You can bundle it for just $30 (20 tablets) with your weight loss prescription. If purchased separately, the cost is $90. NoYes Basic Information First Name Last Name Date of Birth Sex at Birth FemaleMale Phone Please upload a government-issued form of ID (Driver’s License, Passport, etc.). Please be sure that your full name and photo are easily visible. What type of consultation would you prefer? Email and Text Message (Fastest Option)VideoPhone Call How did you find Ness? Please attest to the following confirming that all the information you provided is true and complete. If you do not agree, you may not submit this form. I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. I agree and consent Ness doctors review every form within 24 hours. Do you have any further information which you would like the doctor to know? Payment Information We'll securely collect your payment information now, but you won't be charged until your intake form has been reviewed. If you qualify for medical weight loss, your first month’s prescription will be billed at that time. If you're not eligible, a $30 non-refundable evaluation fee will be charged to cover the cost of the medical review. Card Number Expiration Date (MM/YY) Security Code Name on Card Referral Code (if applicable) Shipping Address Address Apartment, Suite, etc. (Optional) City State Zip Code Is your shipping address the same as billing? YesNo Billing Address Address Apartment, Suite, etc. (Optional) City State Zip Code
