Weight Loss Intake Form | Ness | GLP-1 Weight Loss and Health Concierge

What is your email?*

What are your weight loss goals?*

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 current weight? (lbs)*

Height (feet)*

Please enter a number from 4 to 7.

Height (inches)*

Please enter a number from 0 to 11.

Your BMI is...

Which GLP-1 are you interested in?*

Which state should we ship your medication to?*

Have you ever taken or are you currently taking a GLP-1 medication?*

Yes

Which GLP-1 medication are you currently taking?*

What is the approximate date of your last dose?*

MM slash DD slash YYYY

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.*

Max. file size: 5 MB.

How are you doing with your medication?*

Are you noticing any side effects? Is it working well for you?

If you qualify, would you like to purchase a 3 or 6 month bundle?*

Yes

Which bundle would you prefer?*

Pricing is based on your dosage, please check medication-specific page for exact expected cost.

Are you currently pregnant, breastfeeding, or planning to become pregnant within the next two months?*

Yes

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?*

Yes

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.

Yes

Tell Us About Yourself

Name*

First Last

Phone Number*

Date of Birth*

MM slash DD slash YYYY

Sex at Birth*

Female

Male

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.*

Max. file size: 5 MB.

What type of consultation would you prefer?*

How did you find Ness?*

Consent*

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?

One Last Step

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.

Referral Code (if applicable)

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Is your shipping address the same as billing?*

Yes

Billing Address

Street Address Address Line 2 City State ZIP Code

Your Personalized Weight Loss Plan Begins Here

Tell Us About Yourself

One Last Step

Need Anything?

Need Anything?